afrimedqa/afrimedqa_v2 huggingface dataset:
Specialty: Pediatrics
You are asked to review a 2-month old infant admitted to paediatrics with a severe lower respiratory tract infection. On examination you note that the umbilical cord has not yet separated.

What would your advice to the paediatrician be?


Answer options: option1: Apply daily chlorhexidine to the cord
option2: Suture ligated the excess cord
option3: Investigate for neutrophil mobility defects
option4: Investigate for vertical transmission of HIV
option5: n/a
Correct answer: option3
Rationale: The normal time for separation of the umbilical cord after birth ranges from 3 days to 2 months. Delayed separation of the umbilical cord has been associated with heritable neutrophil mobility defects and widespread infections that are often lethal.
Specialty: Pediatrics
A two-week old newborn is brought to the surgical clinic with and undifferentiated lesion of the umbilicus. Prior to any investigations the parents would like to know what it could be and what it is caused by.

Which of the following options regarding variants of normal embryological structures is correctly paired?


Answer options: option1: Meckel diverticulum originating from the urachus
option2: Umbilical polyp originating from remnants of the omphalomesenteric duct
option3: Umbilical granuloma originating from the omphalomesenteric vein
option4: Patent urachus originating from the allantois
option5: n/a
Correct answer: option2
Rationale: Meckel diverticulum originates from the omphalomesenteric duct. Umbilical polyps are omphalomesenteric duct remnants. Umbilical granulomas consist of granulation tissue only. A patent urachus results from failure of the urachus to obliterate.
Specialty: Pediatrics
A 4 year old girl falls from the balcony of an apartment on the third floor. On arrival in the Emergency Room she is haemodynamically stable. Initial radiographs demonstrate a right femur fracture and bilateral tibia fractures. Her chest radiograph shows no rib or sternal fractures. There is no pneumo or haemothorax. Despite this, her Sats drop to 86% on nasal prong oxygen, and she develops subcostal recessions. 

What is the most likely cause for her respiratory distress?

Answer options: option1: Cardiac contusion
option2: Fat embolism
option3: Aspiration pneumonia
option4: Pulmonary contusion
option5: n/a
Correct answer: option4
Rationale: Pulmonary contusion is the common in children who sustain blunt chest trauma, owing to the increased compliance of the thoracic cavity in a child. As such, the chest can absorb a large amount of kinetic energy from the impact, which is subsequently transferred to the intrathoracic structures. An initial chest radiograph may be normal. Subsequent x-rays may reveal ill-defined consolidation which is not sensitive for contusion, with differentials including aspiration, atelectasis, and infection.
Specialty: Pediatrics
A 12 year old male sustains a penetrating injury to the left chest with a bicycle spoke. His chest x-ray is normal. An ECG shows J-waves and e FAST demonstrates a 4 mm pericardial effusion. The patient remains haemodynamically stable, and is planned for surgical procedure the following day. 

What is the most appropriate procedure in this scenario?

Answer options: option1: a sternotomy
option2: an emergency room thoracotomy
option3: a clambshell thoracotomy
option4: a subxiphoid pericardial window
option5: n/a
Correct answer: option4
Rationale: In this scenario the patient is haemodynamically stable and has a confirmed pericardial effusion. There are no features of cardiac tamponade which would warrant an emergency room thoracotomy, sternotomy or clambshell thoracotomy. The initial surgical management would be a subxiphoid pericardial window. If active haemorrhage is present (indicating a cardiac injury), then the next step would be to convert to a sternotomy in order to repair the injury.
Specialty: Pediatrics
A 6 year old male is brought into the resus bay after being accidentally stabbed in the chest with a pair of scissors whilst playing with his friends at school. He is haemodynamically stable, with a single 1 cm wound on this anterior chest, to the left of the sternum in the 4 th intercostal space. After establishing intravenous access, an erect chest radiograph is done which shows a blunting of the costophrenic angle on the left. 

What is the next most appropriate step in the management of this patient?
Answer options: option1: do an eFAST
option2: insert an intercostal chest drain in the 5th intercostal space mid axillary line on the left
option3: needle decompression on the left 2nd intercostal space
option4: do a CT chest
option5: n/a
Correct answer: option2
Rationale: In this scenario, there is radiographic evidence of a left sided haemothorax. A haemothorax is noted as a meniscus of fluid blunting the costophrenic angle or diaphragmatic surface and tracking up the pleural margins of the chest wall when viewed on an upright chest x-ray film. The most appropriate management is to drain the haemothorax by inserting an intercostal chest drain in the 5th intercostal space, mid-axillary line on the affected side.
Specialty: Pediatrics
A 8 year old male is involved in a motor vehicle accident and ejected from the vehicle. On arrival in the Emergency Centre he has a HR 155 and Sats 88% on nasal prong oxygen. A supine chest radiograph is done which demonstrates fractures of rib 5 and 6 on the right, and ‘veiling’ of the right hemithorax. 

What is the next most appropriate step in the management of this patient?


Answer options: option1: Endotracheal intubation to protect the airway
option2: Insertion of an intercostal chest drain in the 5ths intercostal space on the right
option3: Emergency room thoracotomy
option4: Needle decompression on the right 2nd intercostal space
option5: n/a
Correct answer: option2
Rationale: In this scenario, the child has sustained significant blunt trauma to the chest. Increased density or ‘veiling’ of the right hemithorax on chest radiograph is highly suspicious of a right haemothorax in a supine trauma patient. Because of the supine position of the patient, the haemothorax does not pool in the costophrenic angle but rather distributes broadly across the entire right hemithorax.
Specialty: Pediatrics
A four year old female is brought into a level 1 trauma centre following a pedestrian vehicle accident. Her GCS is 9/15, HR of 140, BP 85/62. On examination her neck veins are distended and trachea is deviated to the left. On auscultation, she has reduced breath sounds on the right. 

What is the most likely diagnosis:

Answer options: option1: Left heamothorax
option2: Right occult pneumothorax
option3: Cardiac tamponade
option4: Right tension pneumothorax
option5: n/a
Correct answer: option4
Rationale: The diagnosis of tension pneumothorax is made clinically. Breath sounds are reduced or absent on the affected side and the trachea deviates away from the affected side. The thorax may also be hyperresonant; jugular venous distention and tachycardia may be present.
Specialty: Pediatrics
A 2-year-old child presents with a slow growing, round subcutaneous lesion on the scalp. It is 2 cm in size and feels superficial, so you proceed to an excision.

Which of the following histological features would confirm the diagnosis of a epidermal cyst?



Answer options: option1: The presence of pilosebaceous units
option2: The presence of hair
option3: A wall composed of true epidermis
option4: Sebaceous material
option5: n/a
Correct answer: option3
Rationale: Epidermal cysts have a wall composed of true epidermis. They do not contain pilosebaceous units or hair. Dermoid cysts are congenital cysts that are lined by skin with fully mature pilosebaceous units
Specialty: Pediatrics
A 4 year old female presents is referred to you for assessment and possible excision of a large neurofibroma in the abdomen, picked up on CT scan. When you examine the child, you have a clinical suspicion of neurofibromatosis Type 1 (NF-1):

Which of the following features, in addition to the neurofibroma, would prompt genetic testing for NF-1?


Answer options: option1: Optic neuritis
option2: Axillary lymphadenopathy
option3: 2 or more café-au-lait spots
option4: Tibial pseudoarthrosis
option5: n/a
Correct answer: option4
Rationale: Genetic diagnosis of NF-1 should be sought is 2 or more of the following 7 clinical criteria are present: six or more café-au-lait spots, two or more neurofibromas or one plexiform neurofibroma, osseous lesion such as sphenoid dysplasia or tibial pseudoarthrosis, first degree relative with NF-1, Lisch nodules, axillary or inguinal freckles, or optic glioma
Specialty: Pediatrics
During a fetal medicine meeting you review the case of a 32 week fetus with ultrasound features of a large mass protruding from the oral cavity. The mass appears to arise from the palate and fills the entire oral cavity. 

Which of the following terms describes a teratoma arising from the hard palate?



Answer options: option1: Epignathus
option2: Congenital Epulis
option3: Desmoid tumour
option4: Cervical teratoma
option5: n/a
Correct answer: option1
Rationale: Epignathus is a term used to describe teratomas protruding from the mouth. These tumors arise from the hard or soft palate or the nasopharynx. They are not to be confused with epulis which is a benign granular cell tumor occurring almost exclusively in girls and arising from the gingival mucosa.
Specialty: Pediatrics
You are call to labour ward nursery to assess a new-born baby with a large right neck mass. The child has mild tachypnoea with no signs of tracheal deviation. You request an MRI which confirms the presence of multiple line as well as adipose tissue and areas of calcifications in the mass

Which of the following is the most likely diagnosis in this case?
Answer options: option1: Foregut duplication cyst
option2: Cervical teratoma
option3: Congenital goitre
option4: Cervical lymphangioma
option5: n/a
Correct answer: option2
Rationale: The scenario provided suggests that this is a congenital neck mass. The MRI findings. All of the above options would be on the differential for a congenital neck mass however the MRI findings are suggestive of a cervical teratoma.
Specialty: Pediatrics
You review a nine month old infant at your clinic, who had a benign sacrococcygeal teratoma resected as a neonate. The alpha-feto protein levels is elevated, and a CT scan is ordered which confirms the presence of recurrence. 

Which of the following is likely to account for the recurrence?


Answer options: option1: a sampling error of the original tumor,
option2: complete resection of a malignant focus with clear margins
option3: progression of malignant disease
option4: the lack of established neo-adjuvant therapy
option5: n/a
Correct answer: option1
Rationale: Most neonatal tumors are mature or immature teratomas that can be managed by surgery and postoperative observation. Recurrent tumors are noted in 10% to 20% of initially benign tumors, and 50% of these are malignant recurrences. The recurrence may be due to a sampling error of the original tumor, incomplete resection of a malignant focus, or transformation of a small benign remnant into
a malignant lesion.
Specialty: Pediatrics
You are referred a 6-day old term neonate with a large sacral mass. Your clinical impression is that of a sacrococcygeal teratoma. 

In order to plan your surgical approach, which of the following investigations would you request?


Answer options: option1: Blood for alpha-feto protein
option2: Ultrasound and/or CT scan
option3: Abdominal radiograph
option4: MRI of the spine
option5: n/a
Correct answer: option2
Rationale: In neonates presenting with large external masses, the degree of pelvic and abdominal involvement should be assessed preoperatively with either ultrasonography, CT, or magnetic resonance imaging (MRI), and these studies may also offer a clue as to the characteristics of the vascular supply. An open or laparoscopic abdominal exploration may be required to mobilize the pelvic portion and to divide the middle sacral artery.
Specialty: Pediatrics
An 4-year-old boy was referred for evaluation of chronic constipation. A contrast enema was ordered to rule out anatomic abnormalities. When performing the enema, difficulty was encountered passing the catheter through the anus. The procedure was aborted an a plain pelvic radiograph showed dysplastic sacral vertebra.

What would you consider next in the work up of this patient?
Answer options: option1: A digital rectal examination to assess for explosive stools
option2: A rectal suction biopsy to investigate for Hirschsprung’s disease
option3: A digital rectal examination to assess for a pre-sacral mass
option4: A augmented pressure distal colostogram to assess for an anorectal malformation
option5: n/a
Correct answer: option3
Rationale: The above scenario describes the late presentation of Currarino triad consisting of an anorectal malformation (commonly anal stenosis), sacral anomalies and a presacral mass
Specialty: Pediatrics
The diagnosis of a SCT is made on antenatal ultrasound. 

Which of the following features would mandate delivery by caesarean section?


Answer options: option1: Tumor size > 10cm
option2: Presence of fetal hydrops
option3: Altman IV SCT
option4: Tumor size >5cm
option5: n/a
Correct answer: option4
Rationale: Abdominal delivery should be considered if the external mass is greater than 5 cm, to avoid dystocia and rupture.60 In-utero shunting can lead to fetal hydrops, which is associated with high mortality
Specialty: Pediatrics
You are asked to see a new born baby in labour ward with a soft mass protruding from the sacral region?

Which of the following clinical features make the diagnosis of a Altman III SCT more likely?


Answer options: option1: Male sex
option2: Associated abdominal mass
option3: When palpating the mass there is no bulging of the fontanelles
option4: Clinical features of Turners syndrome
option5: n/a
Correct answer: option2
Rationale: SCTs are more common in females with a ratio of 4:1. Altman III SCTs have an abdominal component. If the fontanelles bulge on palpation the diagnosis is more likely to be that of a meningomyelocoele. Associated anomalies include Currarino triad, urogenital anomalies, and Klinefelter’s syndrome.
Specialty: Pediatrics
You attend a fetal medicine combined meeting and review the case of a 35 year old primigravida whose antenatal ultrasound done at 24 weeks detects a fetus with a 5 cm sacrococcygeal teratoma (SCT). The mother would like to know how this condition occurs.

Which of the following is most correct regarding the embryology of SCTs?
Answer options: option1: Teratomas are thought to arise from totipotent germ cells in the 8th week of       gestation
option2: Primordial germ cells migrate cranially from the primitive streak
option3: During the 5th week of gestation totipotent primordial germ cells migrate towards the gonadal ridges
option4: SCTs are always remnants of incomplete twinning
option5: n/a
Correct answer: option3
Rationale: Primordial germ cells arise near the allantois of the embryonic yolk sac endoderm and are evident at the fourth fetal week. They migrate along the midline dorsal mesentery to the genital ridge, arriving by the end of the sixth fetal week. There is a theory that some teratomas are a result of incomplete twinning.
Specialty: Pediatrics
You are called to assess a term newborn on day 1 of life, after the paediatrician fails to insert an nasogastric tube. A chest radiograph demonstrates coiling of the nasogastric tube in the neck, and a gasless abdomen 

What is the most likely diagnosis?
Answer options: option1: Oesophageal atresia no fistula
option2: Iatrogenic oesophageal perforation
option3: Oesophageal stenosis
option4: Common type oesophageal atresia with mucus plugging of the distal tracheoesophageal fistula
option5: n/a
Correct answer: option1
Rationale: The most likely diagnosis is oesophageal atresia with no tracheoesophageal fistula (this occurs in 7% of cases of oesopheageal atresia). Iatrogenic oesophageal perforation and oesophageal stenosis are differentials for the finding of a coiled nasogastric tube however one would expect to see air in the stomach/ abdomen. Whilst it is possible to has a gasless abdomen in common type OA/TOF due to mucus plugging of the TOF, this is rare.
Specialty: Pediatrics
A day 2 of life 2 kg neonate is diagnosed with a common type (Gross C) oesophageal atresia with distal tracheoesophageal fistula. 

Which of the following investigations for VACTERL association is required prior to operative intervention?
Answer options: option1: An echocardiogram
option2: A babygram
option3: A renal ultrasound
option4: A spinal ultrasound
option5: n/a
Correct answer: option1
Rationale: All of the above answers form part of the VACTERL workup, however most of these can be completed after surgery, with the exception of the echocardiogram as this has important implications both for the anesthetic and for the surgery (i.e.: in the case of a right sided aortic arch)
Specialty: Pediatrics
A 32-year-old P 1 G 2 female, undergoes an antenatal ultrasound at 22 weeks of gestation. The sonographer notes an AFI (amniotic fluid index) of 28.

What other finding would raise concern for oesophageal atresia?


Answer options: option1: An associated congenital cardiac defect
option2: A double bubble
option3: Small or absent stomach bubble
option4: Hydrops fetalis
option5: n/a
Correct answer: option3
Rationale: The prenatal diagnosis of EA/TEF relies, in principle, on two nonspecific signs: polyhydramnios and an absent or small stomach bubble.
Specialty: Pediatrics
A day one of life tm 2.8 kg neonate is diagnosed with an oesophageal atresia. The babygram shows coiling of the nasogastric tube in the neck and no gas in the abdomen

In this scenario, which of the following is the most relevant indication for bronchoscopy?
Answer options: option1: To identify and inject glue into the distal tracheoesophageal fistula
option2: To identify a proximal fistula
option3: To diagnose tracheomalacia
option4: To occlude the fistula with an endotracheal tube
option5: n/a
Correct answer: option2
Rationale: This scenario describes a neonate with pure oesophageal atresia. The incidence of a proximal fistula, in the absence of a distal fistula, is relatively high and should be investigated with bronchoscopy.
Specialty: Pediatrics
A premature neonate with pure oesophageal atresia, undergoes a gastrostomy for feeding access. The baby is unstable intra-operatively due to an underlying cardiac defect. Post-operatively the baby is ventilated and a Replogle tube in left in the upper pouch.

What is the next most appropriate step in the investigation of this child?


Answer options: option1: Perform a cervical oesophagostomy
option2: Perform a “gapogram” once the baby is stable
option3: Perform a thoracotomy and primary anastomosis once the baby is stable
option4: Perform hydrostatic distension of the upper pouch
option5: n/a
Correct answer: option2
Rationale: In pure oesophgeal atresia, cervical esophagostomy should be avoided at all costs. The gap between the esophageal segments should be periodically measured and is usually expressed in terms of the number of vertebral bodies. This can be done with a simultaneous contrast study of the upper and lower oesophagus, or by insertion of a metal bougie transorally into the upper oesophagus and through the gastrostomy into the lower oesophagus
Specialty: Pediatrics
In a counselling session with the parents of a child born with oesophageal atresia, they ask you how this congenital anomaly occurs. 
 
Which of the following is the most recent theory explaining the normal embryological development of the oesophagus and trachea?



Answer options: option1: Watershed model
option2: Septation model
option3: Outgrowth model
option4: Splitting and extension model
option5: n/a
Correct answer: option4
Rationale: Outgrowth model where the trachea extends from the foregut tube at the level of the lung bud. The Watershed model suggests that both developing trachea and oesophagus elongate from a single diverging. According to the Septation model a septum is formed from lateral ridges of mesenchyme, which moves up along the longitudinal axis of the common foregut tube separating the trachea and oesophagus. The most recent is the splitting and extension model: a ‘saddle-like’ epithelial structure at the distal end of the foregut at the site of lung bud origination moves in a caudal to cranial direction, splitting the foregut in two until the level of the pharynx.
Specialty: Pediatrics
Six weeks after the successful repair of a common type oesophageal atresia, the infant develops difficulty feeding. A contrast swallow demonstrates an oesophageal stricture.

What would the most appropriate management strategy be?

Answer options: option1: Resection and re-anastomosis
option2: Oesophagoscopy and dilatation
option3: Systemic steroids
option4: Topical mitomycin application
option5: n/a
Correct answer: option2
Rationale: Oesophageal strictures are a common problem after repair of an oesophageal atresia. The initial management involves serial dilatation of the stricture.
Specialty: Pediatrics
A 3-month-old infant who had a successful repair of a common type oeosphageal atresia with tracheoesophageal fistula in the neonatal period, is diagnosed with gastro-oesophageal reflux disease (GORD). 

Which of the following statements is true regarding the management of GORD in patients with oesophageal atresia?


Answer options: option1: Most patients with GORD and recurrent strictures will respond to non-operative management
option2: Up to 50% of patients with GORD will require surgical management
option3: A Dor fundoplication is recommended in patients who do not respond to medical management
option4: Nissen fundoplication is the most appropriate initial management
option5: n/a
Correct answer: option2
Rationale: The incidence of significant reflux in patients with EA has been stated to be up to 50%, and about half of these will require anti-reflux surgery. Anti-reflux medication, including gastric acid suppression, is successful in only about half of the cases. While some surgeons have advocated partial wraps because of concerns over dysmotility, there is little evidence to support this practice.
Specialty: Pediatrics
You are called to assess a newborn with a suspected oesophageal atresia. The abdominal radiograph demonstrates a double bubble sign. The child is in respiratory distress, and the neonatologists are planning to intubate.

What is your approach to this scenario?



Answer options: option1: Intubate the right main bronchus to achieve single lung ventilation
option2: Take the child to theatre to perform an emergency gastrostomy
option3: Take the child to theatre and perform a right thoracotomy and emergency ligation of the trache-oesophegeal fistula
option4: Perform a diagnostic bronchoscopy
option5: n/a
Correct answer: option3
Rationale: The scenario describes a neonate with an oeosphageal atresia and distal tracheoesophageal fistula with an associated duodenal atresia. The correct emergency management in this scenario is emergency ligation of the TOF. If intubated, the child will be difficult to ventilate and the stomach will distend and may perforate. Some centres describe doing an immediate bronchoscopy with placement of a Fogarty balloon catheter in the fistula to block it as a temporising manoeuvr, this would be interventional bronchoscopy.
Specialty: Pediatrics
A 2-month old who presented with choking after feeds, undergoes a contrast oesophagogram which demonstrates a trache-oesophageal fistula at the level of C 4

What would your surgical approach be?

Answer options: option1: A left cervical incision
option2: A right cervical incision
option3: A right thoracotomy
option4: Combine bronchoscopic and endoscopic management
option5: n/a
Correct answer: option2
Rationale: The majority of H-type tracheoesophageal fistulas can be divided through a cervical approach with moderate neck extension. A right cervical incision is preferred owing to the more consistent course of the right recurrent laryngeal nerve.