afrimedqa/afrimedqa_v2 huggingface dataset:
Specialty: Pediatrics
NEC is the leading cause of mortality amongst premature neonates. 

Which one of the following statements is most correct regarding the mortality associated with NEC?



Answer options: option1: Mortality is similar in VLBW neonates and ELBW neonates
option2: Mortality is as high as 50% in NEC requiring surgical management
option3: The mortality in recurrent NEC is higher than it is in a single episode of NEC
option4: In some centres mortality in medical NEC is as high as in surgical NEC
option5: n/a
Correct answer: option2
Rationale: With regards to the mortality of NEC, lower birth weight correlates with a higher risk of death. The mortality associated with surgical NEC is significantly higher than medical NEC, with some sources citing up to 50% fatality. The mortality rate in recurrent NEC is similar to that following a single episode.
Specialty: Pediatrics
In his seminal paper in 1975 Santulli hypothesized that the development of NEC requires three things: injury to the intestinal mucosa, bacterial colonisation and a metabolic substrate.

Which one of the following statements is true with regards to the intestinal tract of a premature neonate?


Answer options: option1: The high pH of the stomach is the GI tracts first barrier to infection
option2: Increased motility results in increased epithelial exposure to potentially noxious substances
option3: Mucin secreted by chief cells plays a key role in lubrication
option4: Tight junctions link epithelial cells to form a semipermeable membrane
option5: n/a
Correct answer: option4
Rationale: The acidic (low pH) environment of the stomach is the GI tracts first barrier to infection. Reduced motility results in a slower transit time and thus increased exposure to potentially noxious substances. Mucin is secreted by goblet cells, whereas chief cells secrete pepsinogen. Intestinal epithelial cells form a physical barrier by means of tight junctions which link mucosal poles of epithelial cells to form a semipermeable membrane.
Specialty: Pediatrics
The immune system has a protective effect against NEC, but in the presence of an immature intestinal tract, an initial insult can trigger an exaggerated immune response which can be harmful.

Which of the following statements is true with regards to adaptive immunity in premature neonates?

Answer options: option1: The transfer of IgG across the placenta occurs during the last 4 weeks of gestation
option2: Breast milk contains protective factors such as lactoferrin and lysosyme
option3: T-cells promote intestinal cell regeneration
option4: Breast milk contains the IgA
option5: n/a
Correct answer: option3
Rationale: The gastrointestinal tracts immunological defenses can be divided into passive immunity and adaptive immunity. The transfer of IgG across the placenta and protective factors contained in breastmilk are both part of the passive immunity, whereas T-cells responses form part of adaptive immunity
Specialty: Pediatrics
The prevention of NEC has become a major focus of research because management strategies have had little impact on mortality over the last three decades. 

Which of the following is most clinically effective with regards to the prevention of NEC?


Answer options: option1: Donor human milk contains anti-inflammatory and antimicrobial properties and is as effective as MOM (mothers’ own milk)
option2: Probiotics have been shown to decrease the incidence of Bell II NEC
option3: Amino-acid supplementation with arginine and glutamine shows a significant protective affect
option4: Heparin binding Epidermal Growth Factor is beneficial but concerns have been raised regarding coagulopathy
option5: n/a
Correct answer: option2
Rationale: MOM (mothers’ own milk) has been shown to be more effective than donor human milk in preventing NEC. The use of probiotics has become routine in many parts of the world, as a number of studies have shown a protective effect. Although some small studies were promising, amino-acid supplementation has not been shown to be effective in the prevention of NEC. Heparin binding Epidermal Growth Factor is beneficial however in animal studies it has led to the development of new tumours.
Specialty: Pediatrics
You get called to assess a premature neonate with Bell 3 b NEC. You take the child to theatre for an exploratory laparotomy and find the majority of the small intestine is involved as well as most of the colon. The child has severe metabolic acidosis

You make a diagnosis of NEC totalis based on?


Answer options: option1: involvement of more than 75% of the GI tract
option2: The involvement of more than 50% of the GI tract in a child with severe metabolic acidosis
option3: Intra-operative assessment of bowel perfusion using near-infrared spectroscopy
option4: Intra-operative assessment of bowel viability using Doppler ultrasound
option5: n/a
Correct answer: option1
Rationale: NEC totalis is universally fatal and defined by involvement of more than 75% of the GI tract, diagnosed at laparotomy.  Near-infrared spectroscopy (NIRS) is an emerging modality that may allow an improved assessment of bowel perfusion
in neonates at the bedside. Ultrasound can aid in the diagnosis of NEC.
Specialty: Pediatrics
A day 13 of life premature neonate with a birthweight of 1130 g develops feed intolerance and abdominal distension. The child is hemodynamically stable, with a mildly distended, non tender abdomen and no haematochezia. No bowel sounds are audible. 

Which of the following investigations indicate that this child has confirmed (Bell II) NEC?


Answer options: option1: Loss of cuboidal bowel gas pattern on abdominal radiograph
option2: Pneumatosis in the right iliac fossa on abdominal radiograph
option3: Bowel wall thickening and decreased peristalsis on ultrasound
option4: Rigler's sign on lateral abdominal radiograph
option5: n/a
Correct answer: option2
Rationale: Loss of cuboidal bowel gas pattern on abdominal radiograph and bowel wall thickening o ultrasound are both features of suspected (Bell I) NEC. Pneumatosis intestinalis is the hallmark radiological feature of confirmed (Bell II) NEC. Rigler’s sign (or the double-wall sign) demonstrates a pneumoperitoneum and is a feature of Bell III NEC.
Specialty: Pediatrics
You are asked to assess a day 14 of life premature neonate with a birthweight of 1800 g who develops abdominal distension, coffee ground aspirates and metabolic acidosis. Abdominal xray demonstrates severe pneumatosis intestinalis.

Which of the following is best indicator of the need for surgery?


Answer options: option1: Portal venous gas on abdominal radiograph
option2: A palpable abdominal mass
option3: Abdominal wall erythema
option4: Platelet count of <100
option5: n/a
Correct answer: option1
Rationale: According to Koloske, the best predictors for the need for surgery are: pneumoperitoneum, positive paracentesis and portal venous gas. Good predictors include a fixed intestinal loop, abdominal mass, abdominal erythema. Fair predictors include severe pneumatosis intestinalis. A gasless abdomen with ascites, clinical deterioration, severe GI haemorrhage, abdominal tenderness, PLT < 100 are all poor preditors.
Specialty: Pediatrics
A day 10 of life premature neonate with a birthweight of 1200 g, develops abdominal distension and haematochezia. Abdominal radiograph demonstrates a pneumoperitoneum. You take the patient to theatre for an exploratory laparotomy and find patchy areas of small bowel necrosis with perforation. 

The three main principles of the surgical management of NEC are as follows?



Answer options: option1: Control haemorrhage, prevent contamination, resect necrotic bowel
option2: Control contamination, resect necrotic bowel, preserve bowel length
option3: Proximal diversion with a jejunostomy, resections and mucous fistula
option4: Patch, drain and wait
option5: n/a
Correct answer: option2
Rationale: The principles of surgical of management of surgical NEC are to resect necrotic bowel, control contamination and preserve bowel length. There are multiple  techniques that the surgeon may use to achieve this, including clip and drop, proximal diversion, resection and anastomosis or the formation of ostomies.
Specialty: Pediatrics
You are in the operating theatre performating a laparotomy on a D 17 of life, 1800 g neonate with NEC IIIb. Intra-operatively you find multiple areas of bowel necrosis with perforation. The patient is hemodynamically unstable with severe metabolic acidosis. 

The most appropriate surgical management is?


Answer options: option1: Proximal jejunostomy
option2: Peritoneal drainage and relook when more stable
option3: “Clip and drop”
option4: Enterostomy and mucous fistula
option5: n/a
Correct answer: option3
Rationale: Segmental intestinal involvement may poses an operative dilemma as a large resection may leave the infant with short bowel syndrome (SBS) but failure to resect
injured areas may result in worsening illness or recurrent perforation. In this situation, particularly in an unstable patient the use of a “clip and drop” laparotomy has been widely adopted
Specialty: Pediatrics
Four weeks after performing a limited right hemicolectomy, ileostomy and mucous fistula for NEC 3 b on a premature neonate, you are planning to close the stoma in order to re-establish bowel continuity. 

On this patient, which of the following investigations would you request?
Answer options: option1: A contrast meal and follow through
option2: A contrast enema
option3: An AP and lateral abdominal radiograph
option4: A loopogram through the ileostomy
option5: n/a
Correct answer: option2
Rationale: Strictures occur in 12–35% of infants with medical and surgical NEC. The colon is the most common site for stricture formation, the descending colon in particular, thus a contrast enema is the most appropriate radiological investigation prior to reversal of the ileostomy.
Specialty: Pediatrics
A 6 month old is brought to the surgical clinic by his mother. The infant has torticollis which is limiting head rotation and you notice flatness of the head on the side of the lesion. The mother asks if the child will need surgery.

Which of the following are indications for surgery in this case?


Answer options: option1: Persistent sternomastoid tightness in children more than 3 months of age
option2: Persistent sternomastoid tightness with progressive hemifacial hypoplasia
option3: Diagnosis in children younger than 1 year
option4: Sternomastoid tightness with plagiocephaly
option5: n/a
Correct answer: option2
Rationale: The scenario describes a child with torticollis and plagiocephaly. Surgical management of torticollis due to sternomastoid tumour is indicated in cases of tightness limiting head rotation in children more than 12 to 15 months of age, when associated with progressive hemifacial hypoplasia, and in children diagnosed after 1 year of age. Most children with torticollis and plagiocephaly are managed conservatively with plagiocephaly resolving as the child begins to sit.
Specialty: Pediatrics
You perform surgery for a 4-year-old child with torticollis and progressive hemifacial hypoplasia. 

Which of the following is the correct step to take during the procedure:


Answer options: option1: a transverse skin incision 1cm above the sternal and clavicular heads of the sternocleidomastoid muscle, and division of both heads of the sternocleidomastoid muscle at this level
option2: an oblique incision along the border to the sternocleidomastoid muscle and division of the sternocleidomastoid muscle at its midpoint
option3: a transverse skin incision and division of the sternal head of sternocleidomastoid only
option4: A transverse skin incision and excision of the sternomastoid tumour
option5: n/a
Correct answer: option1
Rationale: Surgical correction of torticollis requires division of both the sternal and clavicular heads of the affected sternocleidomastoid muscle. This is achieved through a 3-4 cm transverse incision in the neck, 1 cm above the insertion of the sternal and clavicular heads.
Specialty: Pediatrics
A 2-month-old infant presents to your rooms with a right neck mass. On examination the mass is firm and not tethered to the overlying skin. The baby’s head is tilted towards the side of the mass.

Which of the following is true regarding the condition described?
Answer options: option1: If left untreated most children with this condition will develop permanent deformity known as plagiocephaly
option2: Surgery is always required to prevent hemifacial hypoplasia
option3: Most children with torticollis are managed conservatively
option4: Botulinum toxin injection is only effective in patients presenting in late  childhood or adulthood
option5: n/a
Correct answer: option3
Rationale: The scenario describes an infant with torticollis and a sternomastoid tumour. Torticollis due to sternomastoid tumour will resolve spontaneously in the vast majority of infants. Surgery is indicated when torticollis does not resolve in infancy, when the diagnosis is made after 1 year of age, and when the torticollis is associated with complications such as hemifacial hypoplasia and plagiocephaly. Boitulinum toxin treatment appears ineffective in patients that present in late childhood or adulthood. Conservative management with physiotherapy in the first year of life is contencious.
Specialty: Pediatrics
A 7-year-old boy is referred to you from the local clinic with a lesion in the floor of his mouth.

What is the diagnosis and management of this lesion?


Answer options: option1: pleomorphic adenoma which requires wide local excision
option2: ranula requiring marsupilization
option3: ranula requiring  excision
option4: siloadenitis requiring aspiration
option5: n/a
Correct answer: option2
Rationale: The above description and photograph demonsrate a ranula. Ranulae are mucus extravasation cysts involving a sublingual gland found on the floor of the mouth. Ranulae are definitively managed by cyst incision and intra-oral marsupilization.
Specialty: Pediatrics
A 2-year-old child presents to your rooms after a hairdresser noticed that the child has mass in the midline of the child’s scalp. On examination, a painless superficial 1 cm mass is felt. The mom is not sure whether it has been there since birth

What would be the next step in the management of this child?

Answer options: option1: Obtain an ultrasound to exclude intra-cranial extension
option2: Do a fine-needle aspiration for cytological diagnosis
option3: Obtain an MRI to exclude intra-cranial extension
option4: Plan for elective excisional biopsy
option5: n/a
Correct answer: option1
Rationale: The scenario above describes a dermoid cyst. Dermoid cysts make up 25% of midline head and neck masses. They are typically painless superficial masses, however midline lesions found on the scalp should undergo ultrasound to exclude intra-cranial extension.
Specialty: Pediatrics
A 1-year-old child presents to your clinic with a midline neck lesion that has been present since birth. You notice some secretions from the lesion. 

What is the surgical management of this lesion?


Answer options: option1: A Sistrunk procedure
option2: A level 1 neck dissection
option3: Radical neck dissection
option4: Complete excision with Z-plasty
option5: n/a
Correct answer: option4
Rationale: The lesion described in the scenario is the typical presentation of a congenital midline cervical cleft.  Surgical excision is recommended for cosmesis, and to prevent abnormalities of neck extension and growth of the mandible. Wound closure by Z plasty avoids linear scarification and attendant limitations in neck extension.
Specialty: Pediatrics
You see a three-month-old infant with a branchial cyst, and you are counselling the parents in preparation for elective cyst excision. The father asks you how branchial cysts come about.

What is the correct description of the embryology of the branchial arches?
Answer options: option1: There are six pairs of branchial arches that contain cranial nerves I to VI
option2: The branchial arches have no ectodermal components, as their external surface become the branchial clefts
option3: Each branchial arch contains a distinct artery, cartilage rod, muscle and nerve
option4: The second branchial arch contains cranial nerves VII and VIII
option5: n/a
Correct answer: option4
Rationale: Neural crest cells responsible for the formation of 6 paired branchial arches migrate to the future foetal head and neck region during the 4th week of gestation. Each arch is separated externally by an ectodermally lined cleft and internally by an endodermally lined pouch. The 5th  pair of arches and associated clefts and pouches regress spontaneously. The remaining paired arches, clefts and pouches each contain a specific artery, muscle, nerve and cartilage rod. The pouch and the cleft of the first arch meet to form the external auditory canal, tympanic membrane and Eustacian canal. The clefts of the 2nd, 3rd, 4th and 6th arches share a common opening at the Cervical Sinus of His and usually regress. The pouches of the 2nd, 3rd, and 4th arches are responsible for the formation of the Palatine tonsil and supratonsillar fossa, inferior parathyroid glands and piriform fossa, and superior parathyroid glands.
Specialty: Pediatrics
A 4-month-old infant is brought to your rooms by her mother, who points out small cutaneous pit on the anterior border of the lower left sternocleidomastoid muscle. She says that it has been there since birth and that recently she has noticed redness around the area.

How would you manage this child?


Answer options: option1: Treat with antibiotics and plan for a biopsy
option2: Obtain an urgent ultrasound of the neck
option3: Treat with antibiotics and plan for elective excision
option4: Obtain an ultrasound to plan for elective excision
option5: n/a
Correct answer: option3
Rationale: The diagnosis of second branchial cleft anomalies is clinical. These anomalies may present as a sinus, fistula, cyst or cartilaginous remnant. Elective excision is indicated given the risks of infection and malignancy associated with branchial anomalies. Excision may be deferred to allow for treatment of an acute infection. Surgical excision attempted during an episode of acute infection may increase the risk of incomplete excision.
Specialty: Pediatrics
A 6-year-old male undergoes a Sistrunk procedure for a thyroglossal cyst. Three months later he develops a midline cervical swelling. 

What is the most likely cause of recurrence?

Answer options: option1: Incomplete excision
option2: Haematoma
option3: Post-operative infection
option4: Excision of the central portion of the hyoid bone
option5: n/a
Correct answer: option1
Rationale: Incomplete excision of the tract and intraoperative rupture are the most likely causes for cyst recurrence. Recurrence occurs in up to 10% of cases.
Specialty: Pediatrics
A 4-year-old female is referred to your practice with a midline cervical mass that moves upwards with protrusion of her tongue. Ultrasound shows solid components, and the thyroid gland is not visualised. 

What is the most appropriate next investigation to obtain?


Answer options: option1: Thyroid functions tests to check for hypothyroidism
option2: Ultrasound-guided fine needle aspiration for cytology diagnosis
option3: Thyroid scintiscan to exclude a median ectopic thyroid
option4: Serum TSH to check for hyperthyroidism
option5: n/a
Correct answer: option3
Rationale: It is important to exclude a median ectopic thyroid gland in any patient with a suspected thyroglossal duct cyst with clinical features of hypothyroidism, or in whom a visible normal thyroid gland is not noted on ultrasound. Approximately, 1-2% of patients with a presumed thyroglossal duct cyst actually have a median ectopic thyroid that is hypertrophied due to the
Specialty: General_Surgery
An adult male with epigastric pain and weight loss, is admitted to the surgical unit. He reports having completed a course of H. Pylori therapy a few weeks earlier but the pain has persisted. Following endoscopic evaluation, it is decided that he undergoes a total gastrectomy for an ulcerative gastric carcinoma.

Name THREE (3) methods for assessing the possibility of Helicobacter Pylori infection in this patient 
Rationale: Urea breath test, 
serology (rapid urease test), 
stool antigen test
Specialty: General_Surgery
What is the treatment for this patient with toxic diffuse goiter 
Rationale: •	Symptomatic management with beta blockers
•	Disease control
a.	Carbimazole/ propylthiouracil
b.	Radioactive Iodine
c.	Dexamethasone/prednisone
d.	Lugols iodine
•	Thyroidectomy when euthyroid
Specialty: General_Surgery
A 45-year-old woman is referred to the general surgical outpatients after her GP noticed a swelling in the neck. On questioning, the patient reports losing about 12 kg in weight over the preceding 3 months, despite having an increased appetite. She also complains that she always feels hot and has to sleep on top of the bed covers at night. Her bowel motions have been loose. On further examination the surgeon makes a diagnosis of Grave’s disease.

What are the initial investigations of this patient?
Rationale: Bloods:
o	Thyroid function tests
o	Thyroid peroxidase antibodies (TPO Abs)
o	TSH receptor antibodies (TR Abs)
Imaging:
o	Ultrasound (USS)
Pathology:
o	Fine needle aspiration (FNA)
Specialty: General_Surgery
A 45-year-old woman is referred to the general surgical outpatients after her GP noticed a swelling in the neck. On questioning, the patient reports losing about 12 kg in weight over the preceding 3 months, despite having an increased appetite. She also complains that she always feels hot and has to sleep on top of the bed covers at night. Her bowel motions have been loose. On further examination the surgeon makes a diagnosis of Grave’s disease.
List FOUR (4) examination signs noticed by the surgeon specific to Grave’s disease 
Rationale: o	Exophthalmos
o	Chemosis
o	Ophthalmoplegia
o	Thyroid acropachy
o	Pretibial myxedema
Specialty: General_Surgery
An adult alcoholic male present with right upper quadrant pain and a low-grade fever for 4 days. On examination he has marked right upper abdominal tenderness extending to the low intercostal spaces. On Ultrasonography a large cystic mass is noted on the right lobe of the liver.

List five (5) aetiologic sources, and the route for each source, for pyogenic liver abscesses 
Rationale: Portal vein  from GI, 
Hepatic artery from septicemia, 
Biliary tree from cholangitis, 
Umbilicus from  sepsis, 
Local extension spread chest, diaphragm, abdominal wall
Specialty: General_Surgery
An adult alcoholic male present with right upper quadrant pain and a low-grade fever for 4 days. On examination, he has marked right upper abdominal tenderness extending to the low intercostal spaces. On Ultrasonography a large cystic mass is noted on the right lobe of the liver.

What specific management would you initiate in managing this patient?


Rationale: Antibiotics, and Aspiration/Drainage
Specialty: General_Surgery
In few words state the standard treatment of first choice after these diagnoses are confirmed

-	Fibroadenosis 
-	Fibroadenoma 
-	Galactocele 
-	Phylloides tumor 
-	Breast cyst Rx 
-	Mastitis 

Rationale: -	Fibroadenosis Rx – Analgesics (NSAIDs)
-	Fibroadenoma Rx - Analgesics
-	Galactocele Rx Repeated aspirations
-	Phylloides tumor Rx – Wide excision
-	Breast cyst Rx – Aspiration or Enucleation 
-	Mastitis – Antibiotics/analgesics
Specialty: General_Surgery
A 35-year-old lady presented with a six months history of a painful breast lump. The pain was cyclical (premenstrual). She is para 4+0 and she breast fed all her children. The breast lump was in the left upper outer quadrant. It measured 2 X 2 cm, not tender, mobile, firm, no clear margins and not attached to the skin. Both breasts felt lumpy and granular. The ipsilateral axillary nodes were not palpable. Other systems were normal. Histological evaluation is negative for malignancy

Enumerate most likely differential diagnoses in this particular patient
Rationale: -	Fibroadenosis. Fibroadenoma. 
-	Galactocele. 
-	Phylloides tumor. 
-	Breast cyst.  
-	Mastitis