afrimedqa/afrimedqa_v2 huggingface dataset:
Specialty: Rheumatology
Concerning humoral immunity, one of the statements is false -

Answer options: option1: The term humoral refers to the cellular components of the blood, such as plasma and lymphatic fluid
option2: The humoral immune response denotes immunologic responses that are mediated by antibodies
option3: Humoral immunity includes the primary and secondary immune responses to antigen
option4: Virgin B cells need to be activated and proliferate before an effective immune response can be generated.
option5: n/a
Correct answer: option1
Specialty: Rheumatology
 Immune dysregulation can result in all these disorders except -

Answer options: option1: Autoimmune disorders, such as autoimmune hemolytic anemia
option2: Inflammatory disorders, such as inflammatory bowel disease or inflammatory     arthritis
option3: Benign tumours such as lymphomas
option4: Allergic disease, such as atopic dermatitis, food allergy, and allergic rhinosinusitis and asthma
option5: n/a
Correct answer: option3
Specialty: Rheumatology
Miss BM presents with polyarthritis, subcutaneous nodules, dry mouth and dry eyes. Anti-cyclic citrullinated peptide was significantly raised. The correct diagnosis of this patient is? ---

Answer options: option1: Complicated rheumatoid arthritis
option2: Rheumatoid arthritis
option3: Primary Sjogren’s syndrome
option4: Secondary Sjogren’s syndrome
option5: n/a
Correct answer: option4
Specialty: Rheumatology
The X-ray of a 52 year old woman revealed marginal osteophytes. Chose the correct statement. 

Answer options: option1: This is a case of rheumatoid arthritis
option2: Osteophyte is associated with scleroderma
option3: This is seen in degenerative arthritis
option4: This is a poor prognostic factor
option5: n/a
Correct answer: option3
Specialty: Rheumatology
Of epidemiology, severity and treatment of systemic lupus erythematosus, one of these statements is correct. 

Answer options: option1: Caucasians are predominantly affected
option2: Black Americans are least affected
option3: Cyclophosphamide is more effective among the Blacks
option4: The condition is worse among the Blacks
option5: n/a
Correct answer: option4
Specialty: Rheumatology
A 19-year-old man presents with low back pain that is associated with morning stiffness. He reports no fever, chills, night sweats, or weight loss. His past medical history is significant for a chronic papulo-squamous skin disorder involving his knees and elbows. On physical examination, forward flexion at the lumbar spine is reduced and there is tenderness of both sacroiliac joints. Rheumatoid factor and ANA are negative. The pathology of back pain is most likely? 


Answer options: option1: Rheumatoid arthritis
option2: Ankylosing spondylitis (AS)
option3: Psoriatic arthritis spondylitis
option4: Reactive arthritis
option5: n/a
Correct answer: option3
Specialty: Rheumatology
A 54-year-old woman with rheumatoid arthritis (RA) presents with symptoms of progressive fatigue. She has no active joint symptoms and her RA is controlled by low-dose methotrexate and NSAIDs. Palpable spleen was the only new finding. Laboratory investigation was significant for a low white cell count [WBC] 2500/m L). Which of the following is the most likely diagnosis for her low white count.
	

Answer options: option1: Methotrexate therapy
option2: Rheumatoid nodules disrupting bone marrow architecture
option3: Felty syndrome
option4: Normal variation
option5: n/a
Correct answer: option3
Specialty: Rheumatology
A 22-year-old woman develops color change in her fingers with cold exposure. The fingers turn white, then blue, and finally red. Which of the following statements regarding this condition is incorrect? 

Answer options: option1: Calcium channel blocker may be of help
option2: May precede the onset of scleroderma
option3: Symptoms can be brought on by vibration or stress
option4: Internal organs are invariably affected
option5: n/a
Correct answer: option4
Specialty: Neurology
Which of the following is not true about reserpine?
Answer options: option1: A.	Reserpine binds tightly to adrenergic storage vesicles in central and peripheral adrenergic neurons for prolonged periods of time
option2: B.	Reserpine inhibits activities of prolactin
option3: C.	The overall result is that of   pharmacological sympathectomy.
option4: D.	Reserpine-induced depletion of biogenic amines correlates with evidence of sympathetic dysfunction and antihypertensive effects.
option5: NONE OF THE ABOVE
Correct answer: option2
Specialty: Neurology
Which of the following is not about cathecolamine synthesis.
Answer options: option1: A.	Dopamine  is converted to NA by dopamine-beta –hydroxylase and requires fe2
option2: B.	Activities of tyrosine hydroxylase is dependent on tetrahydroptridine
option3: C.	The enzyme L-aromatic amino acid decarboxylase affects all naturally occurring amino acids like histidine and trytophan.
option4: D.	The Rate-limiting step is the conversion of tyrosine to L-DOPA due to reduced activity of the enzyme.
option5: NONE OF THE ABOVE
Correct answer: option1
Specialty: Pediatrics
The diagnostic value of tests performed on pleural fluid 
Rationale: Tests that are done help in establishing the following: 
1. Decide whether the fluid is a transudate or exudate. 
2. If the integrity of the pleural membrane is intact the fluid is a transudate. 
3. Impaired integrity of the pleural membrane, with leakage of protein or other large molecules results in an exudate. 
4.  Decide if there is a bacterial or tuberculous infection. 
5.  Decide if there is a chyle in the fluid. 
6.  Determine the aetiology of the fluid. 

Chemical separation of transudate and exudate. 
Transudate: Has protein level of <3g/Dl, LDH < 2/3 of the upper level of serum, pleural/serum concentration ratio of protein of <0.5, pleural/fluid concentration ratio of LDH OF <0.6. 
Exudate: Has a protein level of ≥ 3g/Dl, LDH > 2/3 of the upper level of serum, pleural/serum concentration ratio of protein ≥ 0.5, pleural/ serum concentration ratio of LDH of ≥ 0.6 
Other tests: Bacterial cultures, cell count, adenosine deaminase, and gene X-pert, are also useful. 
Pleural fluid pH > 7.45 or greater than blood Ph is consistent with transudate. Pleural fluid glucose levels are reduced with empyema, TB, and malignancy. A chylous effusion has a normal pleural fluid/ serum glucose concentration ratio ( > 0.5)  and has chylomicrons.
Specialty: Neurology
Which of the following type of patient with myasthenia gravis is most likely to not respond or even worsen with pyridostigminetreatment?
Answer options: option1: A.	patient with acetylcholine receptor antibody positivemyasthenia gravis
option2: B.	patient with muscle-specific tyrosine kinase (MuSK) antibody positive myasthenia gravis
option3: C.	patient with neonatal myasthenia gravis
option4: D.	patient with ocular myasthenia gravis
option5: NONE OF THE ABOVE
Correct answer: option2
Specialty: Neurology
An 85-year-old man who has a history of atrial fibrillation but is otherwise healthy is seen for an assessment of stroke risk. He has hypertension but is not diabetic and besides his atrial fibrillation has no other known heart disease. He has never had a reported neurologic event. According to current data, what is the most appropriate stroke-prevention treatment in this patient?
Answer options: option1: A.	anticoagulation
option2: B.	anticoagulation plus 81 mg aspirin
option3: C.	aspirin 81 mg daily
option4: D.	aspirin 81 mg daily plus clopidogrel
option5: NONE OF THE ABOVE
Correct answer: option1
Specialty: Pediatrics
Discuss the serum-ascites albumin gradient.
Rationale: The exudate-transudate concept with regard to ascites fluid should be discarded in favour of SAAG.
Definition SAAG:  Serum alb – ascites fluid albumin.
SAAG correlates with portal pressure.
SAAG >= 11g/litre (wide SAAG) has a 96% chance of portal hypertension.

Causes wide SAAG (> 11g/l)
a. Chronic liver disease (cirrhosis)
b. Veno-occlusive disease
c. CCF
d. Spontaneous bacterial peritonitis
e. Massive hepatic metastases.

Narrow SAAG (< 11g/l)
a. Reduced plasma oncotic pressure (eg. nephrotic).
b. Tuberculous peritonitis.
c. Secondary bacterial peritonitis.
d. Peritoneal carcinomatosis.
e. Blood and ascites fluid should be sampled simultaneously.
Specialty: Neurology
Which of the following features on neurologic examination is most likely to be associated with a lesion of the cerebellar vermis?
Answer options: option1: A.	Truncal ataxia
option2: B.	Limb ataxia
option3: C.	Lhermite sign
option4: D.	Rhomberg sign
option5: NONE OF THE ABOVE
Correct answer: option1
Specialty: Neurology
A 47-year-old woman reports tingling in her left hand for the past 3 weeks. She wakes up with the tingling at night and also notes it when she is driving. On examination, she has reduced pinprick in the palmar aspect of her first through third digits and the lateral aspect of the fourth digit of the left hand. Strength is normal. Tinel and Phalen signs are absent. What is the most likely diagnosis?


Answer options: option1: Carpal tunnel syndrome
option2: Cervical radiculopathy
option3: Multiple sclerosis
option4: Radial neuropathy
option5: NONE OF THE ABOVE
Correct answer: option1
Specialty: Neurology
A 62-year-old man is seen for subacute onset of generalized weakness and gait changes. Examination is notable for diffusely decreased reflexes, and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is suspected. Which of the following clinical or laboratory findings is concerning for the diagnosis of polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes (POEMS) syndrome as opposed to CIDP?
Answer options: option1: Absence of pain
option2: Aeflexia
option3: Elevated CSF protein level
option4: Presence of lambda light chain
option5: NONE OF THE ABOVE
Correct answer: option4
Specialty: Pediatrics
In a neonate with jaundice, what is the rationale of the following components in exam?
Wellness, 
Colour 
Neurological 
Umbilical 
Rationale:  
1.	Wellness is assessed to help in differentiating whether the jaundice is physiological or pathological. ii. It is also used to assess whether the newborn is preterm or term 

2.	Colour is assessed to trace the severity of the jaundice which is the indication for phototherapy. [Bilirubin check: Palms and sores (15-20mg/dl), Arms and lower limbs {15-18mg/dl), Abdomen (12-14mg/dl), Chest (8-10mg/dl), Face (5- 6mg/dl)]

3. Neurological 
To assess if the bilirubin has crossed blood-brain barrier and affected the brain. For example, in Kernicterus which may lead to complication like cerebral palsy 

4. Umbilical 
a. To check for infections, to check if jaundice is accelerated with infections 
b. Physical bruises
c. To check for entry of infections through bruises, they may also show congenital syphilis
Specialty: Pediatrics
Describe the pathophysiology of physiological jaundice
Rationale: Neonatal physiological jaundice results from simultaneous occurrence of the following two phenomena:
i.	Bilirubin production is elevated because of the increased breakdown of fetal erythrocytes. This is the result of the shortened lifespan of fetal erythrocytes and the higher erythrocyte mass in neonates
ii.	Hepatic excretory capacity is low both because of low concentrations of the binding protein ligandin (Glutathione-STransferase) in the hepatocytes and because of low activity of Uridine-Di-Phospho-Glucuronyl Transferase (UDPGT), the enzyme responsible for binding bilirubin to glucuronic acid, thus making bilirubin water soluble (conjugation).
Specialty: Neurology
A 16-year-old boy is evaluated in the emergency department for deliriumthat developed over the past 6 hours. Examination shows agitation, hallucinations, dry skin, dry mouth, and dilated and unreactive pupils. Temperature is 38.3-C(101-F), heart rate is 120 beats/min, and blood pressure is 110/70 mmHg. Intoxication or withdrawal from which of the following is the most likely cause of the patient’s findings?
Answer options: option1: Anticholinergic intoxication
option2: Cocaine intoxication
option3: Opioid withdrawal
option4: Phencyclidine intoxication
option5: NONE OF THE ABOVE
Correct answer: option1
Specialty: Neurology
A 46-year-old man with hepatitis C is evaluated for abrupt onset of weakness and sensory loss in the left hand and right foot that developed 1 week ago. Examination shows weakness and sensory loss in his left ulnar and right peroneal distributions. Which of the following laboratory findings is most likely in this patient?
Answer options: option1: Antiganglioside antibodies
option2: Antineutrophilic cytoplasmic antibodies
option3: Cryoglobulinemia
option4: Increased kappa/lambda ratio
option5: NONE OF THE ABOVE
Correct answer: option3
Specialty: Pediatrics
Factors that could improve the control of childhood tuberculosis:
Rationale: i)	Better control of adult tuberculosis disease.  Current effective control just 55%.
ii)	Social upliftment – decrease overcrowding, improve nutrition, better contact tracing
iii)	HIV control
iv)	Review immunisation- technique of vaccination, vaccine utilised, host responses.
v)	Adequate isolation facilities.
vi)	Improve compliance –dots program, address issue of MDR tuberculosis management.
vii)	Improve diagnostic accuracy for children with tuberculosis.
viii)	Identification of high risk group for acquiring disease- geographic location, alcohol and cigarette smoking risk habits.
ix)	Use of combination therapy as opposed to single drugs to avoid resistance from appearing.
x)	Ensuring confirmed cases are completely treated and have a team finding defaulters.
xi)	Devise a practical approach to use of prophylaxis in contacts of active cases with tuberculosis.  This is important as regards the current HIV epidemic.
Specialty: Pediatrics
Efficacy vs cost / burden of disease in continued treatment of this patient with childhood tuberculosis very low, thus futility of continued treatment necessitates withdrawal. Ethical principles involved in making this decision include:
Rationale: Autonomy

patient acts intentionally with full understanding of all factors involved with no controlling influences- here the parents act for the patient advocacy
parents 
•	must be fully informed and counseled
•	should not make the decision to withdraw but must be involved at all stages
•	have the right to refuse
•	may need time to accept decision, come to terms with decision
•	allowed to consult others: family members, second opinion, religious leaders etc
respect confidentiality and privacy

Beneficence

Principle of doing good for the patient
Linked here with non-maleficence
Even though this situation seen as futile can still do good for this patient- especially in the implementation of the decision:
-adequate sedation and analgesia
 double effect of sedation: reasonable to administer these drugs even though they   may actually shorten life provided they are not given to shorten life
counsel and comfort parents- physical and emotional comfort

Non maleficence

First do no harm principle.
Continued invasive treatment in a futile situation is ‘doing more harm than good’
Consider also during implementation process- parents and child

Justice

Giving to each that which is his due
Distributive justice- allocation of resources and facilities where these are limited, allocate to more deserving patients. Here continued ventilation in a futile situation can be seen to be depriving another child of a ventilator bed
Handicapped child(survivor) may place large demands on rehab and care facilities in community

Other principles to be considered

Sanctity of life vs Quality of life
Burden of disease
Consider Religious beliefs of parents as well as
Cultural background and customs of parents
Understanding of termination of life vs withdrawal of support- ethical and medico-legal differences 
Paternalistic approach- decision is removed from parents for various reasons- may be ethical
Specialty: Neurology
Your patient has a loss of general sensation and ageusia on the posterior one third of the tongue, and touching the lateral wall of the throat fails to elicit a gag reflex. The neural structure that is the most likely to have been lesioned is the
Answer options: option1: Glossopharyngeal nerve
option2: Vagus nerve
option3: Facial nerve
option4: Trigeminal nerve
option5: NONE OF THE ABOVE
Correct answer: option1
Specialty: Other
Mechanisms of Action of Diuretics
Rationale:  A. Loop diuretics
Examples: Furosamide, bumetanide, torsemide, ethacrynic acid.  Leads to excretion of 20 to 25% of the filtered Na+ when given in maximum dosage.  Act on the medullary and cortical aspects of the thick ascending limb, including the macula densa cells in the early distal tubule.  At each of these sites Na+ entry is primarily mediated by a Na+ K+ 2Cl- carrier in the luminal membrane that is activated when all 4 sites are occupied.  The loop diuretics appear to compete for the Cl- site on this carrier, thereby diminishing net reabsorption. Also, inhibiting the reabsorption of NaCl leads to a parallel reduction in the reabsorption of Ca2+ thereby enhancing Ca2+ excretion.
B. Thiazide-Type Diuretics
They primarily inhibit sodium and chloride transport in the distal tubule, the connecting segment at the end of the distal tubule, and possibly the early cortical collecting tubule. Since these segments reabsorb less of the filtered load, these diuretics are less potent, inhibiting at most 3 to 5 percent of the filtered Na+. The thiazides inhibit NaCl reabsorption in these segments by competing for the Cl- site on the Na-Cl cotransporter.  Another important action is the increased reabsorption of Ca2+ in the distal tubule and cortical collecting tubule.  The fall in Ca2+ excretion is useful in the treatment of recurrent kidney stones due to hypocalciuria.  
C.  Potassium-Sparing Diuretics
3 major ones:  Amiloride, spironolactone and triamferenc.  They act in the principal cells in the cortical collecting tubule (and possibly in the papillary or inner medullary collecting duct). These drugs act by decreasing the number of open Na+ channels.  Spironolactone does this indirectly by competitively inhibiting the effect of aldosterone.  
D.  Mannitol
This is a nonreabsorbable polysaccharide that acts as an osmotic diuretic.  Its main mechanism of action is by inhibiting Na+ and water reabsorption in the proximal tubule and more importantly, in the loop of Henle.  It produces a relative water diuresis in which water is lost in excess of Na+ and K+.  It can increase plasma osmolality by 2 mechanisms

a)	The preferential water diuresis following repeated administration can lead to a water deficit and hypernatraemia.
b)	Hypertonic mannitol may be retained in patients with renal failure, directly increasing the plasma osmolality.  

In this setting, water movement out of cells down an osmotic gradient will lower the plasma Na+ concentration by dilution.  This is an important condition to recognise, since treatment must be aimed at the hyperosmolality, not the hyponatraemia.
Fluid and Electrolyte  complications of diuretic therapy
•	Volume depletion
•	Azotaemia
•	Hypokalaemia
•	Metabolic alkalosis 
•	Hyperkalaemia and metabolic acidosis with K+ -sparing diuretics.
•	Hyponatraemia, especially with the thiazides
•	Hyperuricaemia 
•	Hypomagnasaemia
Specialty: Neurology
A patient suddenly can no longer read or write. He seems to speak normally, although he misuses words, and he understands and executes simple motor commands. Later testing reveals that he cannot add and subtract, and he cannot identify which fingers are which. You suspect that his lesion has affected the
Answer options: option1: Splenium of the corpus callosum
option2: Angular gyrus
option3: Arcuate fasciculus
option4: Paracentral lobule
option5: NONE OF THE ABOVE
Correct answer: option2
Specialty: Pathology
MANTOUX TEST
Rationale: IMMUNOLOGICAL
Delayed hypersensitivity (type IV hypersensitivity) reaction to PPD.  These reactions are mediated by T cells and monocytes/macrophages rather than by antibodies.  The Mantoux test itself is a delayed hypersensitivity reaction. Thus, 48-72 hours following the intradermal administration of purified M tuberculosis protein derivative, patients who have been exposed to the bacteria develop a delayed hypersensitivity reaction manifested by inflammation and edema in the dermis.
POSITIVE MANTOUX
Normally > 10 mm
If BCG, > 15 mm
If immune suppressed, > 4 mm
Pos = infected with MTb
FACTORS
•	Technique of administration, storage
•	Booster effect
•	Type of PPD
•	Immune status
•	Previous BCG
•	Exposure / time of exposure to TB
•	Severity of TB infection
•	Live virus vaccines
•	medication
Specialty: Pediatrics
Discuss Iron metabolism.
Rationale: Iron is essential for the functioning of all cells.

Diet:  must contain 10mg+ of iron daily (absorption of dietary iron 10%). 1mg iron must be absorbed daily.

Sources of iron: Heme iron (meat etc.) – more bio-available.
                           -  Non-heme iron (plant based food, egg, etc).
                           -  Also endogenous turnover.
Absorption:  occurs in duodenum, upper jejunum. increase with low iron stores and if increased rate of erythrocyte  production.
                     -  ferrous form of iron better absorbed.
                     -  decrease when iron stores are high.
Absorption also enhanced by Vit. C;  inhibited by phytates, tannin.

Transported in blood by transferrin to bone marrow (after heme was split in intestinal mucosal cell with release of iron).

Total body iron = 70% used in metabolic processes.
                          = 10%-30% stored in RES as ferritin.
Some stored as hemosiderin (insoluble form).
Specialty: Neurology
A 55-year-old man presents for evaluation of left-sided facial weakness. The symptoms started 1 day ago and worsened over the past 24 hours. He has a history of diabetes mellitus, which is well controlled with medications and diet. Examination reveals moderate left lower motor neuron facial weakness. He also has vesicular lesions on the left anterior tongue. What is the most likely diagnosis?
Answer options: option1: Bell’s palsy
option2: Neurosarcoidosis
option3: Pontine infarction
option4: Ramsay Hunt syndrome
option5: NONE OF THE ABOVE
Correct answer: option4
Specialty: Neurology
Your patient has a lesion that has resulted in a loss of touch sensations in the face. The patient still feels pain and temperature sensations, and there is no jaw weakness. The neural structure most likely affected is the
Answer options: option1: Aspinal nucleus of V
option2: Trigeminal ganglion
option3: Principal nucleus of V
option4: Mesencephalic nucleus of V
option5: NONE OF THE ABOVE
Correct answer: option3
Specialty: Pediatrics
Write Short Notes Production of cerebrospinal fluid.
Rationale: Cerebrospinal fluid (CSF) is produced within the cerebral ventricular system, mainly the choroid plexus (villous folds lined by epithelium and a central core of highly vascularised connective tissue).  

Active secretion and diffusion to paired lateral ventricles to foramen of Munro to single midline third ventricle to the aqueduct of Sylvius to Fourth ventricle to exits through 3 openings (lateral foramina of Luschka and midline foramen of Magendie to cisterns in subarachnoid spaces to cisterns in posterior fossa through the pathways over the tentorium over the cerebral convexities to sagittal sinus to absorbed to systemic circulation.  

Fluid is also absorbed across the ependymal lining of the ventricular systems and from spinal subarachnoid space.

CSF production approximately 20ml/hour; turns over 3-4 times per day.