THE COLLEGES OF MEDICINE OF SOUTH AFRICA Incorporated Association not for gain Reg No/Nr 1955/000003/08

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1 THE COLLEGES OF MEDICINE OF SOUTH AFRICA Incorporated Association not for gain Reg No/Nr 1955/000003/08 DCH(SA) Examination for the Diploma in Child Health of the College of Paediatricians of South Africa 20 March 2012 Paper 2 Scenario 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, i.e. be clear and concise. 5 You may answer the questions in Afrikaans, if you wish. 1 Write short notes on a) Steps you would initiate in your community to increase awareness of paediatric cancers and ensure earlier presentation. (10) b) The clinical features and early management of spinal cord compression. (10) c) How to determine the age of an abandoned infant or child. (10) d) The importance of the routine 6 week examination of an infant. (10) 2 Write short notes on a) Your approach to a 4-year-old with polyarthritis. (10) b) How to make the diagnosis of pulmonary TB in children. (10) c) The radiological and cutaneous manifestations of non-accidental injury. (10) d) The differential diagnosis of chronic diarrhoea in a 3-year-old child. (10) PTO/-Page-2-Question-3

2 -2-3 Write short notes on a) The management of status epilepticus. (10) b) The rationale for introducing the Rotavirus, Pneumococcal and Human Papilomavirus vaccines into the South African immunisation programme (EPI). (10) c) The interhospital transport of a sick newborn baby. (10) d) How you would manage an outbreak of gram negative sepsis in the children s ward of a district hospital. (10) 4 Write short notes on a) A 15-year-old girl presents to casualty as she had consensual, unprotected sex 48 hours previously and is now concerned about the risk of pregnancy and sexually transmitted infections. Explain how you will manage her and discuss the legal and ethical obligations of treating her. (10) b) Your local district hospital has recently purchased a continuous positive airways pressure (CPAP) machine. Discuss what is required to use it and how you would assist the hospital in setting it up for use in a preterm baby with hyaline membrane disease. (10) c) Write short notes on the management of a 5-year-old who has been bitten by a snake. (10) d) Describe your approach to a 3-year-old child who is not yet talking. (10) 5 Write short notes on a) The use of intravenous immunoglobulins in children. (10) b) The features and management of meningococcal septicaemia in a child. (10) c) Seborrheic dermatitis. (10) d) The clinical and radiological findings in congenital syphilis. (10)

DCH(SA) Paper 3 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

3 DCH(SA) Paper 3 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 22 March 2012 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 succinctly. 4 You may answer the questions in Afrikaans, if you wish. Question 1 Andile is a 45-day-old male infant who presents to the emergency room. Following an initial assessment the medical officer s records note the following Weight 2.8 kg (under -3 z score) Height 52 cm (just under -2 z score) Weight for height score (under -3 z score) General exam: Axillary Temp 38.6 o C. Pink tongue although the fingers and palms are cool and pale. Capillary filling time 3.5 seconds. No jaundice, clubbing, oedema or lymphadenopathy. Respiratory: rate 55 breaths per minute with indrawing of the lower chest and an expiratory wheeze. Cardiovascular: pulse rate 180 beats per minute, radial pulse are hard to feel (the femoral pulse is more easily palpable than the radial pulse but also weak). BP hard to detect but systolic pressure of 35 mm Hg (<5 th percentile for age). Normal heart sounds, no murmurs nor gallop. Abdomen: not distended and no organomegaly detected. CNS: lethargic with decreased spontaneous movements, but not unconscious.

4 -2- a) Classify Andile s nutritional status using the information provided. (2) b) His circulatory status is clearly unsatisfactory would you classify this as compensated or uncompensated shock (circulatory insufficiency)? Justify your answer. (2) c) List TWO signs you used to make this assessment of his circulation. Indicate how you interpreted each sign. (4) d) Indicate your initial treatment of Andile s shock and how you would assess response to this treatment. (2) e) Tabulate the possible causes of shock in infants by pathophysiological mechanism. For TWO of these pathophysiological causes indicate the typical features, and the key management. (10) It is difficult to differentiate between serious (often bacterial) illness and viral conditions. f) What clinical features will help to differentiate between a serious bacterial and viral infection. (4) g) Tabulate FOUR special investigations that you will use to help decide if Andile has a serious bacterial infection. For each indicate how you will interpret the investigation and whether the investigation is inexpensive, expensive or very expensive. (4) You decide that Andile has clinical signs and special investigations suggestive of a serious bacterial infection. In addition you can see that he has not improved despite your initial attempt to treat his shock. h) Identify 4 likely sites for infection in Andile based on his findings and on your knowledge of the sites of serious bacterial infection in young infants. (4) i) What are the 4 most likely organisms that might have caused Andile s bacterial infection? (4) j) Based on the findings and your knowledge of serious bacterial infections in young infants which antibiotic(s) would you choose and why? (4) Question 2 Thabo, a 3-year-old boy is brought to the emergency room of your district hospital by his mother. He is irritable and inattentive with a respiratory rate of 40 breaths per minute with deep sighing respiration. He is deeply cyanosed and clubbed. His heart rate is 140 beats per minute. The apex beat is in the 5 th intercostal space, mid-clavicular line, S1 is normal, S2 is single and there is a 2/6 soft pulmonary ejection murmur. Thabo s mother says that he has not been sick but squats and goes blue once every 2 to 3 days for the past month. PTO/Page 3 Question 2a).

5 -3- a) Describe the immediate management of Thabo s condition. (6) b) What is your diagnosis? Explain your answer. (2) c) What TWO further investigations, available in your hospital, would you perform and what do you expect each of them to reveal? (4) d) Once Thabo is stable you decide to refer him to a tertiary hospital because, as you explain to his mother, you believe he may require surgery. What treatment would you commence before referral? (2) On further assessment you note that Thabo has clinical features of Trisomy 21. e) Explain the genetics of Down Syndrome and what tests you would do to confirm the diagnosis. (6) f) Does the Down Syndrome alter your decision to offer him surgery? Justify your answer. (3) g) Who should make decisions about the distribution of resources and access to care for children such as Thabo? (3) You read a paper that indicates that screening for cyanotic congenital heart disease can be done within hours of birth through the use of pulse oximetry. This resulted in early diagnosis of this conditon. h) How will you use pulse oximetry to screen for congenital cyanotic heart disease? (4) i) Describe FIVE principles of a good screening test. (5) j) Considering these principles discuss whether screening for congenital heart disease is appropriate for South Africa. (5) Question 3 Yvodia, a 3-year-8-month-old female is brought into the paediatric casualty with a 3 day history of vomiting, headache and neck stiffness. She is HIV positive and on antiretroviral therapy. Since becoming ill her mother reports that she has stopped moving the left side of her body. Her BP is 100/60, pulse rate 128 beats per minute and axillary temperature 37.8 o C. Yvodia has spontaneous eye opening and is responding unintelligibly to questions. She is opisthotonic. The tone is decreased on her left side and the power reduced to 1/5 in her left arm and 3/5 in her left leg. Her deep tendon reflexes are brisk on the left with an upgoing plantar reflex on the same side. There are diffuse crepitations in her lungs and a 4cm liver and 3cm spleen are palpable on abdominal examination. Bowel sounds are normal. You make a provision diagnosis of meningitis and in light of a family history of Tuberculosis you suspect it is TB meningitis (TBM). PTO/Page 4 Question 3a).

6 -4- a) Describe the CSF features that would support your suspicion of TBM and indicate how you would differentiate between TBM and a partially treated bacterial meningitis. (5) b) Describe the pathophysiology of TBM. (4) c) What are the criteria for diagnosing TBM? (2) d) How is TBM classified (staged). What is Yvodia s classification? (3) e) What is the Cushing reflex? Was it present in this instance? (2) f) How will you treat Yvodia? Tabulate the drugs and indicate the dose and the duration of treatment for each. (5) g) Explain why Yvodia is not moving the left side of her body. (1) h) What radiological investigation would you request to assist in determining the cause of her immobility and what do you expect it to reveal? (2) Yvodia has generalised tonic-clonic seizures. Her U&E shows a Na + of 117 mmol/l and a repeat lumbar puncture reveals that the CSF protein has increased to >5 g/l. i) List TWO possible complications that could account for the seizures and indicate how you would mange each. (4) j) You decide to start maintenance anticonvulsants. Which drug will you choose? Justify your choice. (4) Yvodia starts drooling and is unable to swallow. k) Explain the significance of these signs and discuss how you will manage the problem. (4) l) What counselling would you offer Yvodia s family regarding her long term prognosis? (4) Question 4 Jonathon is 8-years-old and presents to your clinic with an eight week history of abdominal distension. a) List FOUR possible causes of abdominal distension that you would consider. (4) b) List FOUR features that will make you suspect that the distension may be due to a renal mass. (4) Following a full clinical examination you decide that there is a mass in the renal area. c) List FIVE clinical signs that you would evaluate to establish a possible cause for this renal mass, and indicate the significance of each. (5) PTO/Page 5 Question 4d)...

7 -5- Despite a careful and complete examination you are still unsure of the cause of this renal area mass and consider it to be of either renal or adrenal origin. d) What THREE basic radiological examinations could you do in a small peripheral (district) hospital? Indicate how each test may help you to decide on the possible cause of the mass. (6) Based on your clinical examination and radiological results you decide that this is probably a renal mass, most likely a nephroblastoma. Jonathon s blood pressure is 140/120. e) You wish to confirm this BP. Describe briefly how you will take a child s blood pressure manually. (4) f) What is the normal BP for a boy of this age? What will you do about Jonathan s blood pressure? (3) A full blood count shows a Hb of 7,4 g%, MVC 60 fl, MCH16 pg. The white cell and platelet counts are normal. g) What abnormalities are present on the blood count and how do you explain these? (4) You believe that the most likely diagnosis is a nephroblastoma but are unsure and feel that you need to refer Jonathon for further treatment. h) Who do you refer him to? (2) His mother wants to know what further tests are going to be done. i) Name THREE important tests that you think will be done at the referral centre to confirm the diagnosis? (3) j) What explanation will you offer Jonathan s mother, in broad terms, about the management plan you expect to be implemented at the referral centre. (3) The mother is very worried when you tell her that her child may have a possible renal tumour. k) What are Jonathan s likely chances of survival in a first world (resource-rich) country and in a third world (resource-poor) country? (2) PTO/Page 6 Question 5

8 -6- Question 5 Injury and violence is a major killer of children throughout the world, accounting for about deaths each year in children and young people under the age of 18 years. Unintentional injuries account for almost 90% of these cases and are the leading cause of death for children aged years. An audit of your hospital casualty admissions showed the following statistics of childhood injuries for the period December 2011 and January There were 290 children admitted. AUDIT OF CASUALTY DEC 2011/JAN BURNS MVA NEAR POISONING DROWNING OTHER MVA = Motor vehicle accident a) Discuss FOUR possible household factors in South Africa that contribute to childhood injury. (4) b) Discuss FOUR possible factors in the community that contribute to childhood injury. (4) Further breakdown of the data according to age and gender shows the following number of admissions in each category for the more common modes of injury: Injury Boys Girls < 1 year 1-4 years 5-9 years >10 years Burns MVA Near drowning Poisoning Other c) Describe TWO age and TWO gender differences in the type of injury experienced, and explain these differences. (4) PTO/Page 7 Question 5d)...

9 -7- Further analysis of admissions as a consequence of motor vehicle accidents reveals the following Cause <1 year 1-4 years 5-9 years >10 years Total Pedestrian Unrestrained passenger Restrained passenger Cyclist Total d) Describe FOUR risk/behavioural factors contributing to MVA s involving children. (4) e) What THREE preventative measures would you proposed to reduce childhood accidents i) In the household. (3) ii) At a community level. (3) iii) In a health institution. (3) f) Describe the role of the health sector in reducing the morbidity and mortality from MVA s. (3) The overall global rate for drowning among children is 7.2 deaths per population, though with significant regional variations. The drowning rate in low-income and middle-income countries is six times higher than in high-income countries (with rates of 7.8 per and 1.2 per , respectively). For those children who survive drowning, many are left with long-term consequences and disability that create enormous difficulties for families, with prohibitively high costs of health care. g) Outline how you would manage a 3-year-old child with near drowning at the scene of the emersion. (5) This audit stimulates your interest in the subject and in your reading you discover that non-natural deaths account for 4% of all under-5 deaths in South Africa. This ranges from 2.3% in the Free State which has the highest under-5 mortality to 9.3% in Western Cape with the lowest under-5 mortality. Furthermore non-natural deaths account for 1.0% of deaths in the first month of life, 2.7% of all deaths in the first year of life, 12.5% of deaths between 1 and 4 years of age and 22.9% of deaths in children h) aged 5-14 years. Explain the differences in geographic areas as well as ages between the provinces. (4) h) Explain the differences in geographic areas as well as ages between the provinces. (4) i) List THREE recommendations for improved public awareness of child safety. (3)

THE COLLEGES OF MEDICINE OF SOUTH AFRICA Incorporated Association not for gain Reg No/Nr 1955/000003/08

THE COLLEGES OF MEDICINE OF SOUTH AFRICA Incorporated Association not for gain Reg No/Nr 1955/000003/08 DCH(SA) Examination for the Diploma in Child Health of the College of Paediatricians of South Africa