THE COLLEGES OF MEDICINE OF SOUTH AFRICA

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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 20 August 2013 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) Steps you would undertake to control an outbreak of head lice at a local primary school. (10) b) Ethical considerations and the legal status of circumcision of male newborn infants and children in South Africa. (10) c) The 2013 South African national PMTCT programme. (10) d) The rationale and process for including HPV vaccine into the EPI schedule. (10) 2 Write short notes on a) The management of haemophilia A. (10) b) The presentation of insulin dependent diabetes mellitus in a child. (10) c) The radiological and cutaneous manifestations of non-accidental injury. (10) d) Haemorrhagic disease of the newborn. (10) 3 Write short notes on a) The primary and secondary prevention of rheumatic fever and rheumatic heart disease. (10) b) The diagnosis and management of attention deficit hyperactivity disorder. (10) c) The public health response to a diagnosis of acute flaccid paralysis. (10) d) The management of an acute mild-moderate asthmatic attack. (10) 4 Write short notes on a) Acute phase reactants and their use in clinical practice. (10) b) The role of physical education in the school curriculum. (10) c) The clinical presentation and management of organophosphate poisoning. (10) d) Your approach to the management of a 4-week-old infant with jaundice. (10) 5 Write short notes on a) The audit cycle in paediatrics. (10) b) Paediatric triage. (10) c) Breastfeeding support in primary care. (10) d) Surgical causes of vomiting in infancy. (10)

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 21 August 2013 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 succinctly. 4 You may answer the questions in Afrikaans, if you wish. Question 1 Jabu weighs 2.37 kg at birth. He appears to be term. His mother, Thembi, was not well during the last trimester of her pregnancy, but was not admitted to hospital. She is HIV negative. Jabu is her first child. You are the medical officer at the hospital. a) Offer three possible reasons why Jabu may be of low birth weight. (3) b) How would you decide if Jabu is preterm or small for gestational age? (2) c) List two diseases that Jabu may be at risk for as an adult because of his low birth weight (particularly if he gains excessive weight later in life). (2) Jabu is started on breastfeeding 30 minutes after birth. Jabu s blood glucose (glucometer) is noted to be 2.1 mmol/l four hours after birth. He appears well. d) How would you respond to this? (4) Thembi is unsure about the effectiveness of her breastfeeding technique. You assess her feeding. e) Describe three signs that would suggest that Jabu s breastfeeding attachment and/or positioning are satisfactory. (3) Jabu is discharged 72 hours after birth. He is well. f) Indicate three key messages related to breastfeeding practice that you would offer Thembi. (3) g) Should Jabu be offered nutritional supplements, such as multivitamins, at discharge? Explain. (1) PTO/ Question 1 continue

4 -2- At the 14 week clinic visit, Jabu is still being breastfed. Thembi is keen to commence formula feeds and baby foods, since she intends commencing work in a fortnight. His weight is 5.6 kg (weight-for-age z-score = -1.96). h) What advice will you offer her? (4) You next see Jabu when he is 8-months-old. He presents with a cough. Jabu s weight is 6.9 kg (weight-for-age z-score = -2.31). You note some palmar pallor. Your unit practices IMCI. i) How would you interpret Jabu s weight-for-age z-score? (1) j) How would you respond to this? (2) k) What is the significance of the palmar pallor? (1) l) How would you respond to this? (2) There are three main ways that the nutrition of children can be supported. m) Explain the meaning of each of the following AND its relevance for Jabu. i) Food diversification. (2) ii) Food supplementation. (2) iii) Food fortification. (2) At his 18 month clinic visit, Jabu s weight is 10.1 kg (weight-for-age z-score = -0.73), and his length is 76 cm (length-for-age z-score = -2.08). n) How will you interpret Jabu s length-for-age z-score, i.e. how will you categorise his length? (1) o) What is the likely reason for this? (1) p) What is the prevalence of this condition in young South African children? (1) q) List two longer-term consequences of failing to manage this condition. (2) r) What advice would you offer Thembi related to Jabu s length? (1) Question 2 Sister Rogers has been posted to Kleinmond clinic after her community service. She was trained in the Integrated Management of Childhood Illness (IMCI) at her nursing college. Sr Rogers phones you in your district hospital for advice on the management of Claire, a fourmonth-old girl who has a cough. She admits that she can remember almost nothing from her IMCI course, but she can remember that she had to look for general danger signs. a) Name THREE IMCI Danger signs. (3) b) What steps should she take if she identifies any one of them? (3) Fortunately, Claire has no general danger signs. Sr Rogers asks you to remind her of what she should ask and look for to assess and classify the cough. c) What should she ask and look for and how would she use the information to classify Claire s respiratory problem according to IMCI? (5) PTO/ Question 2 continue

5 -3- The child's classification is severe pneumonia. You agree that the child must be referred to your hospital s casualty. d) How should Sr Rogers manage Claire before the ambulance arrives? (3) e) What equipment should the ambulance have on board in order to transfer Claire safely? (3) Claire arrives on oxygen with oxygen saturations of 94%. Her respiratory rate is 76 breaths per minute and her pulse 148 beats per minute. Her chest is moving symmetrically with marked intercostal and subcostal recession. There is marked bilateral hyperinflation, reduced breath sounds equally bilaterally, with a few crackles heard. The heart is clinically normal and she is fully conscious. f) Describe your emergency management at this point. (5) Claire's breathing eases. The person accompanying her is her father s sister who does not live with the family. She has Claire s Road to Health Booklet. g) What THREE pieces of essential information, required to manage Claire s respiratory disease optimally, would you seek in the Road to Health Book? (3) Claire s tachypnoea and recession persist and her oxygen saturations on nasal oxygen remain unchanged. h) Outline your approach to further special investigations of Claire. (3) Your diagnosis is an acute uncomplicated bronchiolitis in an otherwise normal infant. i) Outline the inpatient management plan for the following 48 hours. (5) Claire recovers well. Her parents are there when you discharge her. j) Outline TWO points you will communicate to them about Claire s health. Explain why you are highlighting each of these points to the parents. (4) k) Outline how and what you will communicate to Sr Rogers at the clinic. (3)

6 Question 3 You are the medical officer on call in outpatients. It is a Friday evening and there is a long queue of patients waiting to be seen. Your first patient is Annie, a 1-year-old girl, with a 2 day history of watery loose stools and vomiting. She weighs 10 kg. She has never been admitted to hospital before and is growing well. All immunisations are up to date. Her parents work for the local University; her mother is a biology lecturer and her father is a professor of physics. This is their only child. You examine Annie and find her to be moderately dehydrated. You explain to her parents that she has acute gastroenteritis with dehydration. She will need to be admitted for a trial of oral rehydration. The parents are very anxious. They ask you the following questions. Provide a response. a) What is acute gastroenteritis? (1) b) What causes it and why did our daughter get it? (2) c) We have recently read in the newspapers that some children who had bloody stools developed kidney failure. What illness did they have and why did they develop kidney failure? (2) d) Does Annie have this? (1) e) Why are you not giving Annie a drip? Will that not work much faster? (2) f) What is in the oral rehydration solution and how does it work? (3) Annie s parents agree to the oral rehydration strategy. g) How much fluid will you prescribe? (2) h) What fluid will you prescribe? (1) i) How often should fluids be offered? (1) At the 2 hour review, Annie is still moderately dehydrated and is not drinking well. Her parents are now even more anxious. j) What will be your next management step? (3) At the 4 hour review, she still has profuse watery diarrhoea and her capillary refill time is 4 seconds. Urine output is uncertain as the diarrhoea is so profuse. Annie is sleepy but very irritable when you wake her up. k) How will you manage her? (3) The blood chemistry result obtained at this stage shows: ph 7,10; pco2 3,5 ; HCO3-14 mmol/l; Na 172 mmol/l; K 2,6 mmol/l. l) Indicate how you would manage each biochemical abnormality. (8) Later that night Annie has a generalised tonic-clonic seizure. m) How will you manage the seizure pharmacologically? (1) n) How will you explain the likely cause for the seizure to Annie s parents? (2)

7 Annie s condition slowly improves over the next few hours and her parents are much happier. You go home. When you arrive on duty on Monday, you start with Annie. She still has diarrhoea; and her mother tells you that this is now the 6th day. She is no longer vomiting. Annie s mother asks you the following questions? Provide a response. o) Why have the doctors prescribed Zinc? (2) p) Will you have to do further tests to see why the diarrhoea is not stopping? (3) q) The diarrhoea seems worse every time she is given milk to drink. Why is this?" (1) r) What will you do for the ongoing diarrhoea? (2)

8 Question 4 Peter is a 5-year-old brought into your Regional Hospital Outpatient Department. His mother complains that he has had a bulging right eye for the last week. He is able to see with the eye. a) List TWO possible causes of the bulging eye. (2) Peter has bilateral proptosis with the right eye much worse than the left. All the cranial nerves are intact including vision. You also notice lumps and bumps on the scalp. A skull x-ray shows no lytic lesions in the bone. You examine the abdomen and feel a mass in the left upper quadrant. b) List THREE clinical features suggesting a renal area mass. (3) c) You think it is a renal area mass. What is the most likely diagnosis? (1) d) List FOUR other clinical features that would support this diagnosis. (4) You decide to admit Peter to the ward for observations and investigations. The intern is inexperienced. e) Explain to him how to check Peter s blood pressure as the automated BP machine is out of order. (4) You do urine and blood tests. Urine VMA and HVA are markedly raised. FBC shows a pancytopaenia. f) What diagnosis do these results confirm and what stage is the malignancy? (2) g) What is the prognosis for Peter s tumour? (1) Peter develops epistaxis. A repeat FBC shows a platelet count of 4 x10 9 /dl and haemoglobin of 2,5 g/dl. h) Write out the prescription for the blood products you would order. (4) i) What 2 special radiological investigations would you like to perform? (2) j) The tumour you are suspecting can occur in other sites. List 2 other primary sites for this tumour. (2) The intern phones you and says the BP is now 190/140. k) What is the normal BP for a child of this age? (2) l) How are you going to manage this BP? (2) m) How soon and where do you refer Peter? (2) n) What treatment do you expect them to give initially? (1) Proptosis is one of the Red Flag signs for paediatric cancers. o) List FOUR other such signs. (4) p) What are the THREE commonest malignancies in children? (3) q) Is cancer a notifiable condition? (1) PTO/ Question 5

9 -6- Question 5 Lwandile is a 2-year-old girl, referred to you from a local clinic because her mother complains that she is excessively sleepy during the day and has very noisy breathing, especially at night when asleep. a) What sign is Lwandile s mother describing? (1) b) Is this sign normal in children? Explain. (2) Lwandile is running around your consulting room and appears quite healthy. c) While taking the history, what specific information would you elicit further, to make an assessment of airway obstruction above the larynx? (5) d) What are the main clinical signs of airway obstruction at this level? (4) e) What are the main causes of airway obstruction above the larynx? (4) f) Why is it easy to miss airway obstruction above the larynx? (2) You decide that Lwandile has airway obstruction above the larynx. Knowing that there is a long waiting list for patients to be assessed and managed in your ENT service, you need to ascertain the severity of the obstruction so that if severe, your will be able to refer Lwandile urgently. g) What specific information would you elicit in the history to ascertain the severity of the obstruction? (2) h) On examination what would you look for to assess severity of the obstruction? (4) What investigations would you do? i) To assist with the diagnosis. (2) j) To assist with the severity assessment. (4) You decide that Lwandile has severe obstruction above the larynx and needs to be admitted to your ward. k) What observations would you ask the ward staff to do? (4) All your findings confirm severe obstruction needing urgent ENT intervention. Lwandile has no other medical problems. l) Which of the causes of obstruction listed in (e) is the commonest? (1) m) What intervention is indicated for this cause? (1) n) What perioperative care should be provided? (4)