THE COLLEGES OF MEDICINE OF SOUTH AFRICA. Examination for the Diploma of Child Health of the College of Paediatricians of South Africa.

Transcription

1 DCH(SA) THE COLLEGES OF MEDICINE OF SOUTH AFRICA Incorporated Association not for gain Reg No/Nr 1955/000003/08 Examination for the Diploma of Child Health of the College of Paediatricians of South Africa 18 March 2014 Paper 2 Short note type questions (3 hours) Instructions 1 Answer each of the following FIVE (5) questions in separate books. 2 Each question has 4 sub-questions. Answers to each sub-question should be approximately words (not more than 1 page) in length. 3 Each question is worth 40 marks and each sub-question is worth 10 marks. The whole paper is worth 200 marks. 4 The aim is to check your ability to express objective knowledge with precision, ie be clear and concise. 5 You may answer the questions in Afrikaans, if you wish.

2 -2-1 Write short notes on a) The aetiology and emergency management of neonatal seizures. (10) b) The causes of under 5 mortality in South Africa and list key priority child health interventions adopted to address these causes. (10) c) The management of febrile convulsions. (10) d) The differential diagnosis of a 1-year-old child with a barking cough and stridor and how you will differentiate between the conditions. (10) 2 Write short notes on a) The Apgar test and its role in predicting long-term outcome. (10) b) The off-label use of drugs in children. (10) c) The major causes for spontaneous acute, painful unilateral scrotal swelling in an infant and how you would investigate this condition. (10) d) The likely causes and relevant investigations for haematochezia (the passage of fresh blood per rectum) in an eighteen-month-old baby. (10) 3 Write short notes on a) What one needs to consider when obtaining consent for an HIV test on a 2-year-old child living with her grandmother, and her mother lives 500km away. (10) b) Four notifiable paediatric conditions; why these conditions are notifiable and the process required notifying these conditions. (10) c) The early warning signs of cancer in children. (10) d) The relative advantages and disadvantages of oxygen administered by nasal prongs and oxygen mask in children. (10) 4 Write short notes on a) The approach to a child with recurrent headaches. (10) b) The risk factors for obesity in children. (10) c) The initial management of a 3-year-old child presenting with a history that he can t talk. (10) d) The contra-indications to vaccinations in children. (10) 5 Write short notes on a) The typical clinical features, clinical course and management of primary herpetic gingivostomatitis. (10) b) Ready to use therapeutic foods. (10) c) Complications and prevention of bacterial meningitis. (10) d) The diagnosis and management of iron deficiency anaemia in children at the district hospital in South Africa. (10)

3 -3- DCH(SA) THE COLLEGES OF MEDICINE OF SOUTH AFRICA Incorporated Association not for gain Reg No/Nr 1955/000003/08 Examination for the Diploma in Child Health of the College of Paediatricians of South Africa 19 March 2014 Paper 3 Scenario based questions (3 hours) Instructions 1 Answer each of the following FIVE (5) questions in separate books. 2 Each question is worth 40 marks. The whole paper is worth 200 marks. 3 Answer questions briefly and precise. 4 You may answer the questions in Afrikaans, if you wish. Question 1 Gerald is a previously well 3-year-old boy. He attends a pre-school facility daily. His mother brings him to casualty with an itchy skin rash for 2 days. She mentions that another child at the pre-school had a similar rash 2 weeks ago. You examine Gerald and find clear fluid-filled vesicles on his trunk. He is otherwise clinically well. a) What is the most likely diagnosis? (1) i) List TWO other conditions which may present with clear vesicles in children. (2) b) What is the cause (aetiological agent)? (1) c) What is the incubation period? (1) d) How will you manage Gerald at this stage? (3) e) When can he return to pre-school? (2) 3 days later Gerald returns. He now looks ill and toxic. His temperature is 39 C, pulse rate 155 beats/minute and respiratory rate 46 breaths/minute. There are crusts and new vesicles with red areas around them. PTO/Page 2 Question 1 f) f) What is your assessment of Gerald s condition now? (2)

4 -4- g) How will you manage him now? (5) h) List FIVE other complications of his initial illness that may develop. (5) His mother mentions that Gerald has a 2-year-old sister at home who has never had a skin rash like this. i) What advice will you give Gerald s mother regarding his sister? (2) j) Can this condition be prevented? (1) k) Elaborate on your answer to j). (4) l) Gerald s grandmother wants to treat him with aspirin, what is your opinion on this advice? (2) Gerald s pre-school teacher is pregnant. She develops the same rash and delivers a term baby the next day. m) How will you manage this situation? (2) n) What are the dangers if the teacher s baby develops the illness and how would you manage the baby? (5) o) Discuss your plan for the follow-up of the teacher s baby. (2) Question 2 Sibongile is an 11-year-old boy. He is brought by his grandmother to the HIV treatment clinic for his routine monthly visit. He was initiated on antiretroviral therapy (ART) 13 months ago. His HIV viral load (VL) after 6 months of treatment was lower than detectable limits (<50 copies/ml). The results of his 12 month VL is copies/ml. His mother died when he was very young and his grandmother doesn t know where his father is. a) What are the first line treatment regimens for children initiating ART in South Africa? (4) b) Discuss THREE ways in which treatment failure can manifest. (6) c) Discuss how you would approach and manage Sibongile s rising viral load. (10) After talking to his grandmother you discover that she has caught him throwing his tablets in the dustbin when he thought she wasn t looking. When confronted, he refused to take the medication saying that he doesn t have to take it and none of his friends take tablets. His grandmother then tells you that Sibongile does not know that he is HIV-positive or why he has to take medication. She is scared to speak to him. d) Discuss HIV disclosure in paediatrics. Include the following aspects i) Who should disclose the HIV status to children? Justify your answer. (5) ii) Benefits of HIV disclosure to the child and the caregiver. (5) iii) The timing of disclosure - What information would you provide to children at different ages (eg < 5 years; 5 7 years; 8 11 years; > 11 years)? (5) PTO/Page 3 Question 2 e)

5 -5- e) When Sibongile is 15-years-old, his VL is undetectable and he has a normal CD4 count, discuss the process of transition from care in a paediatric setting to that in an adult setting.(5) Question 3 A previously well, four-year-old boy, Lucky, is found semi-conscious by his mother. They live in informal housing and Lucky had been playing in a nearby refuse tip. In the ambulance, on the way to hospital he vomited twice and passed a loose stool. He was also reported to have had what appeared to be a tonic-clonic seizure. Examination reveals the following General: He is frothing at the mouth. His oxygen saturation is 85% in room air. His heart rate is 80 beats/min and regular. His blood pressure is 65/40 mmhg. Neurological System: He is semi-comatose but attempts to withdraw his limb in response to a painful stimulus. He moans incomprehensively in response to pain. He does not open his eyes throughout the exam. He has generalised hypotonia with absent tendon reflexes. His pupils are pin-point bilaterally and they don t respond to light. You note slight fasciculation of the tongue. There are no localising signs. Respiratory System: There are bilateral coarse crackles and diffuse wheezes. a) What is the Modified Glasgow Coma Scale for infants and children score for Lucky. Explain how you reached your score and how does this compare with the AVPU score. (8) b) Would you intubate Lucky? Motivate your answer. (5) c) The treating clinician decides to intubate Lucky. Describe how you would perform an emergency intubation for Lucky; include discussion of any drugs that may be useful. (10) d) What is Lucky s most likely diagnosis? (2) e) How would you confirm this diagnosis? (3) f) Describe the clinical management of Lucky. (10) g) What are your public health obligations in this case? (2) Question 4 Khathu, a 3-year-old boy presents with diarrhoea for 4 days; initially watery stools, but now with fresh blood mixed with the stool. He vomited all oral fluids administered at his local clinic. On examination he had lethargy, some pallor, sunken eyes and growth parameters were normal. a) Define IMCI. (1) b) Using IMCI, how would you classify Khathu s illness and justify your answer? (6) c) List the TWO danger signs that Khathu has. (2) d) List FOUR common infectious causes of diarrhoea in children. (4) e) Discuss the immediate management of Khathu in the casualty. (4) f) List FOUR important signs that you would advise the mother to look out for and when to come back immediately to the health care centre after discharge of Khathu. (4) PTO/Page 4 Question 4 g)

6 -6- The results of laboratory tests reveal: (normal range in brackets) Haemoglobin 6.5g x10 9 /L ( X10 9 /L) MCV 87 fl (70-86) WCC 26 X10 9 /l (6-18X10 9 /L, Platelets 65 X10 9 /l ( x10 9 /L) Reticulocyte count 6.5 % ( %) g) Interpret these results. (4) h) List TWO further blood investigations you would request. Justify your answers. (4) Despite your management Khathu becomes oliguric and further blood tests show (normal range in brackets) Urea 23mmol/l ( mmol/l) Creatinine 60μmol/l (14-34μmol/L) i) What is the most likely diagnosis? (1) j) Name the FOUR most common causes of this condition. (4) k) What would you expect to find on the peripheral blood smear in this condition? (1) l) List FIVE complications of this condition. (5) Question 5 A 6-year-old child is referred by his grade R teacher with concerns that he can t sit still in the class and he often does not finish the tasks given. The teacher thinks that the child s development is slow especially when compared to the rest of the class. On examination you find him to be microcephalic, underweight for his age, as well as stunted. On general examination he has facial dysmorphism in the form of a thin upper lip and small palpebral fissures. You are concerned about a diagnosis of fetal alcohol syndrome (FAS). a) What are the diagnostic features of FAS? (5) During the consultation he is unable to sit still, is generally disruptive and fidgety. b) What condition, apart from his FAS, would you consider and how would you confirm the diagnosis? (5) c) Discuss the medical management of this condition. (4) d) What general recommendations would you make to his mother and grade R teacher before referring him for further management? (5) e) Name THREE other health care professionals who should be part of the management of this child and identify their respective roles in his care. (6) The developmental assessment reveals that he is functioning at the level of a 4-year-old child. His mother would like to enrol him for grade 1 at a mainstream school for the next year. f) What advice will you give his mother regarding his school placement and the ongoing support that he will need? (5) PTO/Page 5 Question 5 g)

7 -7- On further enquiry, the mother confesses that she still consumes alcohol regularly and sometimes leaves him alone over a weekend while out drinking. g) What steps would you take to ensure this child s safety? (5) h) Discuss this case in terms of the rights of the child. (5)

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