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

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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 Paper II 17 March 2010 (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) Zinc supplementation in diarrhoeal disease. b) Indications for testing an infant or child for cystic fibrosis. c) Warning signs of malignancy in children. d) The management of a child admitted with suspected cholera. 2 Write short notes on a) Snoring in children - why is it significant, complications and management. b) Causes of hyperactive behaviour in young children. c) What would make you consider that an acutely ill neonate is suffering from an inborn error of metabolism? d) The causes, complications and management of masturbation in young girls. 3 Write short notes on a) The diagnostic features and management of post traumatic stress disorder in children. b) Your approach to a 13-year-old girl who requests advice on contraception. c) The differential diagnosis, natural history and management of undescended testes. d) The clinical consequences and hospital management of near drowning. PTO/ Page 2 Question 4

2 -2-4 a) A child is referred from school after failing Grade 1 for a second time. List and categorise possible causes. b) Annotate the normal neurodevelopmental milestones of an eighteen month old baby. c) You start a new job at a rural hospital. The perinatal mortality rate at the hospital is 60/1000. The under 5 mortality rate for the area is 90/1000 and the infant mortality 70/1000. The stillborn: neonatal death ratio is 1:1. i) Define perinatal, infant and under 5 mortality rate. (3) ii) What is South Africa s under 5 mortality rate? (1) iii) What is the likely quality of newborn and paediatric care at this hospital? iv) Motivate your answer. (2) List 4 interventions that could have a significant impact on reducing childhood mortality in this region. (4) d) Tabulate the age of consent for each of the following, based on the new Children s Act (of 2005) and other pertinent legislation i) Age of majority (becoming an adult). ii) Incapable of consenting to sex. iii) Capable of consenting to sex. iv) Surgical procedures. v) Medical procedures. vi) Terminating a pregnancy. vii) Sterilization. viii) Access to contraceptives. ix) HIV testing. x) Child can be prosecuted. 5 Write short notes on a) Causes for blood in the stool in a 9-month-old infant. b) Advice you would offer to a mother who is worried that her baby does not get enough breast milk. c) The management of allergic rhinitis in children. d) The management of primary enuresis in a 6-year-old boy.

3 THE COLLEGES OF MEDICINE OF SOUTH AFRICA DCH(SA) 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 Paper III 18 March 2010 (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 Edward, a 4-year-old boy, presents to the paediatric casualty with a warm, tender, swollen knee with reduced range of movement. He apparently fell while playing soccer about 2-3 hours ago. a) List FOUR possible clinical diagnoses you would consider. (4) You perform appropriate investigations. The only relevant results are: Prothrombin time (PT): 9 sec (N<10sec) Partial thromboplastin time (PTT): 100 sec (N<44 sec) b) What would be the most likely diagnosis now? (1) c) What further test would you request to confirm your suspicion? (1) The further test result comes back as 1%. d) What is your full diagnosis at this stage? (3) You decide to admit Edward as he is unable to walk and seems to be in severe pain e) What treatment(s) would you prescribe for his knee problem? (6) Edward s mother, a nursing sister, arrives some time later. You are now able to take a full history from her. f) What is important to ask her about in the family history? (3) You find out that there is a family history of a similar problem in two of the mother s brothers. Her father was not affected by this disease.

4 g) Draw Edwards s genogram (family tree) starting with the mother s parents (her father was normal) to demonstrate the inheritance pattern of this disease. (9) h) Name the inheritance pattern. (1) Edward s mother is worried by the severity of the condition, and wants to know under what circumstances she should bring him in to see a doctor in the future. i) List FIVE possible reasons why she should bring him to the hospital for you to evaluate. (5) Four days later, Edward s knee is much better and he is fully mobile. You decide to discharge him. j) List FOUR aspects that you need to pay attention to or need to arrange so as to optimize his future treatment. (4) Six months later you once again see Edward in the outpatient department. The mother complains that the treatment that she gives at home, when needed, seems to be less effective and the swelling of the joints does not get better as quickly as previously. k) List THREE possible reasons why Edward should suddenly have stopped responding to his treatment. (3) Question 2 Ziyanda, an 8 month old boy, was admitted to your district hospital s paediatric ward during the night by the on-call medical officer (MO). You take over his management this morning. Ziyanda has had a high fever for 3 days, poor feeding and a runny nose. His mother brought him to the hospital as she noticed a rash developing on his face, that subsequently extended to his body. The MO was unsure of the cause and diagnosed a possible viral infection and prescribed paracetamol. Ziyanda is miserable, has a temperature of 38 C despite a recent dose of paracetamol, and has a diffuse maculopapular rash involving his face, neck, trunk, arms and legs. He also has a persistent cough. His respiratory rate is 52 breaths/min and the oximeter saturation is 94% in room air. a) What is the most likely diagnosis? (1) b) Suggest THREE possible differential diagnoses. (3) c) What ONE other specific sign, which if present, may support your likely diagnosis? (1) On further history-taking you discover that Ziyanda was admitted to your hospital the previous month with a diagnosis of bronchiolitis. His routine immunisations are up to date. d) What preventive measure should have been instituted during the previous admission that could have prevented the current illness? (1) e) Outline your clinical management. (5)

5 f) What specimen(s) would you send off to the laboratory to confirm your diagnosis (Include the method of transport and procedure). (4) g) You are concerned about nosocomial spread of this infection. Outline your approach to preventing other children in the ward acquiring this disease. (3) h) Ziyanda has a 3 year old sister at home, and his mother is concerned that she is also at risk. What would you advise her? (2) i) You are aware of the need to monitor Ziyanda for complications. List THREE potential non-respiratory complications and indicate how you would manage each of these if they occurred. (6) You are on call that night and the nurse calls you as she is concerned that Ziyanda seems to be having greater difficulty breathing. You examine him and note that he has inspiratory and expiratory stridor. j) What complication has he developed? (1) k) Outline your management (4) Scenario conclusion l) What is the usual natural history of this illness after the occurrence of the rash? (2) m) What is your public health responsibility related to this case? (1) n) Briefly describe the epidemiology of this condition in South Africa between 1990 and 2010, and explain any variations.. (4) o) There was an outbreak of this disease nationally in Explain the possible reason(s) for this. (2) Question 3 A 5-month-old infant, Peter, is brought by his mother to Casualty with a history of a sudden onset of a generalized convulsion followed by an apnoeic spell. Clinically he is lethargic. You notice petechiae on his face, some redness around his neck and abdominal tenderness. a) List THREE possible differential diagnoses. (3) b) List FOUR signs you specifically would look for during your clinical examination, and the significance of each? (4) c) List FIVE investigations you would undertake, and indicate why each may be helpful? (5) Based on further findings you decide to order a CT scan. The brain scan shows acute and chronic subdural haematomas. A chest radiograph shows posterior rib fractures at the level of T4 and T5 and a radial fracture of the humerus. d) Based on these findings, what is your primary diagnosis now? (1) e) What is the likely explanation for the subdural haematomas? (1) f) List THREE key additional pieces of information that you would acquire from Peter s mother to assist you in excluding other causes for the findings? (3) g) What additional information would assist you in deciding whether the child is at risk for further injury should he be discharged back home? (3)

6 h) What additional clinical documentation do you need to complete (other than routine case notes? (1) i) List THREE medical and/or other professionals you will need to contact to assist in further case management? (3) Peter s mother indicates he cries all the time. She confesses to occasionally getting very angry when she is unable to quieten him. j) How are you going to manage the case clinically? (4) k) What are your legal and ethical commitments in this case? (2) l) What law governs your responsibility in this case? (1) m) What is Peter s longer-term prognosis? (2) n) What should the long term management of Peter include? (3) Following further investigation, it is decided that a criminal prosecution is warranted. You are summoned to attend the court proceedings. o) Outline your responsibilities as a professional witness? (4) Question 4 Two year old Joseph presents with a history of confusion, weight loss over the past month and a stiff neck. A diagnosis of tuberculous meningitis is made following a lumbar puncture. Joseph weighs 9 kg. a) What are the classical lumbar puncture findings you would expect in a child with tuberculous meningitis? (2) b) What anti-tuberculous drugs (including dosages) would you prescribe? (4) A routine HIV Elisa test is positive. According to Joseph s mother she tested HIV negative during pregnancy. Joseph s CD4 count is 10% of his total lymphocyte count with an absolute count of 370 cells/ml. His viral load is copies/ml. c) Stage his HIV disease. Motivate your answer. (2) d) Explain when you would commence anti-retroviral treatment (ART). (2) After appropriate counseling you decide that Joseph needs to be started on ARTs. e) Describe an appropriate ART regiment for Joseph and motivate your choice. (10) f) List two other (non ART) drugs you would add to his treatment. (2) The local clinic requests a management plan for Joseph for the next twelve months so that they may make arrangement for medication and supplies. g) Describe this plan. (9) You are going away for a year s sabbatical. You decide to orientate the new medical officer who will take over the running of the HIV clinic.

7 h) Describe NINE possible complications or adverse events that Joseph may develop over the next twelve months. (9) Question 5 Martin, a 7-week-old baby boy has been referred from a clinic because of a bloody nasal discharge for a few days. He also has a rash on his soles and palms. Martin was born at home, 5-weeks premature. His birth weight was 2.3 kg. He is his mother s fifth child. He has been breastfed since birth. She first attended antenatal clinic at 16 weeks pregnancy and tested HIV negative. Martin now weighs 3.08 kg. His pulse is 176/min, respiratory rate 62/min, temperature 37.1 C. He is grunting and has flaring nostrils. The oxygen saturation is normal and the peripheral pulses are easily palpable. He is pale, deeply jaundiced and has generalized lymphadenopathy. The abdomen is distended, a liver is palpable 5 cm beyond the costal margin, as well as a 4 cm spleen. You notice that he is not moving his right arm. a) Explain each of the following findings, i.e. what is the underlying aetiology or significance of each sign. i) Birth weight of 2.3 kg ii) Grunting iii) Pallor iv) Jaundice v) Generalised lymphadenopathy vi) Abdominal distention vii) 5 cm liver and 4 cm spleen viii) Not moving right arm (8) b) What is the most likely diagnosis? (1) You decide to admit Martin. These are results of initial investigations: Total bilirubin: 100 μmol/l Conjugated bilirubin: 75 μmol/l AST: 512 U/l ALT: 115 U/l Glucose: 1.9 mmol/l Na: 138 mmol/l K: 4.1 mmol/l Urea: 3.4 mmol/l c) Which abnormality requires urgent attention and what would you do? (5) d) Interpret the liver function test results. (2) e) List FOUR conditions that may present with conjugated hyperbilirubinaemia in a 7- week-old infant. (4)

8 The full blood count results are: Hb: 5.2 g/dl MCV 100 fl WCC: 48.8 X 10 9 /l 65% neutrophils, toxic granulations, lots of band cells Platelets 62 x 10 9 /l f) Interpret the full blood count results. (3) g) How will you respond to this result? (2) h) List THREE laboratory, radiological or investigations that you would consider undertaking at this stage to establish a specific diagnosis, and explain how each may assist you in the management of this child.. (3) Two days later you receive a call from the laboratory to say that the Rapid Plasma Reagent (RPR) test is positive to a titre of 1:64. i) How would you interpret this result? (2) j) What tests, investigations or procedures (other than to confirm the primary diagnosis) would you now consider performing? (2) k) Outline your further management of this case. (6) l) What advice will you offer to the mother to prevent her next baby being affected by the same condition. (2)