THE COLLEGES OF MEDICINE OF SOUTH AFRICA. Examination for the Diploma in Child Health of the College of Paediatricians 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 in Child Health of the College of Paediatricians of South Africa 10 February 2017 Paper 2 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 precisely.

2 2 Question 1 Thabo is a 4-year-old boy who is referred to you with a history of strange behaviour for 1 week as well as a sore neck and a poor appetite. He has no past medical history of note and is not on any medication. He has a negative HIV ELISA documented in his Road-to-Health Booklet. On examination you find that he is stunted with a weight for age below -2 z-score. He is apyrexial with a normal pulse and normal respiratory rate. He is confused with a Glasgow Coma Scale (GCS) of 14/15 and has neck stiffness. The rest of his clinical examination is unremarkable. a) List FIVE (5) causes of neck stiffness, other than meningitis. (5) You decide to perform a lumbar puncture (LP) on Thabo. b) List FIVE (5) contra-indications to doing a LP. (5) Thabo has no contra-indications and you perform a LP. The results are as follows: Polymorphs 20, Lymphocytes 300, Erythrocytes 0, Glucose 2.2mmol/L, Chloride 99mmol/L, Protein 2.4g/L c) What is the most likely diagnosis? (1) d) What else can be requested on the CSF to help confirm your diagnosis? (2) e) What is your severity assessment for Thabo s disease? Justify your answer. (3) f) Which medication will you use to treat Thabo? Include the doses and duration of therapy for each drug. (7) Thabo s GCS is slowly deteriorating and you suspect that he is developing hydrocephalus. You don t have access to a CT or MRI scan. g) What test can you do to differentiate communicating from non-communicating hydrocephalus? (1) h) Outline how you would perform the test and how you would interpret it? (6) Your test shows that Thabo has a communicating hydrocephalus. i) Which TWO (2) drugs will you add to his treatment? (2) Two days later Thabo has a generalised tonic-clonic convulsion. You perform some blood tests with the following results: Glucose 4.6mmol/L, Sodium 115mmol/L, Potassium 3.7mmol/L, Calcium 2.4mmol/L. j) Which abnormality do you see in the blood test results? (1) k) List TWO (2) possible causes for this abnormality in Thabo s case. (2) l) How can you differentiate these TWO (2) possible causes clinically? (2) m) How would you manage this abnormality? (3) PTO/Page 3 Question 2

3 3 Question 2 Thandi is an 8-year-old girl. She is brought to your district hospital outpatient department by her mother who reports that Thandi has been unwell for the last 5 days. She has been tired and is losing weight. She is thirsty all the time and passes urine frequently. She has even started wetting the bed at night for the first time since she was 4-years-old. Yesterday she developed abdominal pain and vomiting. Today she is confused, lethargic and breathing fast. You are informed that her aunt has sugar sickness. a) List THREE (3) differential diagnoses for polyuria and polydipsia, other than Diabetes mellitus. (3) b) What complication is Thandi currently experiencing? (1) c) What Bedside tests are available to help you support your likely diagnosis? Tabulate your tests and the expected result. (3) d) Explain the pathophysiology of her symptoms (i) Polyuria; (1) (ii) Weight loss; (1) (iii) Vomiting; (1) (iv) Fast breathing. (2) e) Describe your immediate management of Thandi? (6) f) What are the principles of the long-term management of Thandi s condition? (6) Thandi was transferred to the tertiary hospital in the city where she improved from her initial presentation. Since then she attends a specialist clinic at the tertiary hospital every 3 months where she receives her treatment. She presents again to your district hospital casualty at 03h00 when you are on call. Her mother says she went to check on Thandi at 02h30 and found her to be clammy, sweaty and unresponsive and she was unable to rouse her. Thandi s haemo-gluco test (HGT) done by the nurse in casualty is 1.0mmol/L g) List THREE (3) possible causes for this hypoglycaemic episode. (3) h) How will you manage her hypoglycaemic episode? (3) i) What will you teach her mother to do if she has a hypoglycaemic episode at home and: (4) (i) She is awake and alert; (ii) She is not rousable. She recovers and is kept overnight for observation. Apart from this episode- her mother says Thandi has adjusted well to her treatment and her blood glucose is generally well controlled. She is also doing very well at school. Her mother complains though that the trips to the city and special food for Thandi are expensive and she is not coping financially. She asks if Thandi qualifies for a grant. PTO/Page 4 Question 4 j)

4 4 j) Name TWO (2) grants that you would consider for children. For each type of grant state: (i) The eligibility criteria; (ii) The amount paid out. (6) Question 3 Vuyo is born by vacuum extraction after his mother, Lindi, became too tired to push during the last few minutes of delivery. Lindi is a 16-year-old primigravida in grade 10 who was unbooked. The second stage of her labour lasted 3 hours. At delivery Vuyo struggled to breathe and the attending midwife had to resuscitate him. His Apgar scores were 3/10 at 1 min, 4/10 at 5 min and 6/10 at 10 mins. His birthweight was 3.8kg. a) What investigation would you perform in order to confirm that this is Hypoxic Ischaemic Encephalopathy (HIE) secondary to birth asphyxia? Give the investigation and the result which would support the diagnosis. (2) He is stabilised and transferred to the ward where you perform a severity assessment on him. b) List SEVEN (7) clinical parameters that you could use to assess Vuyo s neurological status. For each parameter indicate the possible abnormalities. (7) c) HIE is one cause of neonatal encephalopathy. List FOUR (4) other causes and one investigation that you would perform to obtain supporting evidence for each cause. (8) d) Discuss your initial management of Vuyo. (6) You notice that many babies in your facility are born with HIE. You also notice that the mortality rate from this problem is increasing in your facility. e) What program is used to review neonatal deaths in our country? (1) f) List THREE (3) programs in South Africa aimed at improving neonatal outcomes. (3) Vuyo is discharged home and is lost to follow up. He had been sent to live with an aunt in the Eastern Cape. He returns at 18 months. On examination you find that he can sit with support, is able to reach out and hold a cube in each hand and vocalises to attract his mother s attention. g) What would you assess his developmental age to be? (1) h) What are the appropriate milestones for his age? (4) i) What is the long term management of Vuyo s developmental delay? (4) Lindi says that she has heard an advert on the radio saying that if you have a disabled child it is possible to get money from the hospital to help the family take care of him. j) Does Lindi have a right to pursue litigation against the Department of Health? (1) PTO/Page 5 Question 3 k)

5 5 k) As a Department of Health employee, what advice do you give her regarding her options if she feels that the care she received was substandard? (3) Question 4 Samantha, a healthy 1-year-old girl, attends a child day-care facility as her mother has just returned to work. Barely a month after starting there she becomes ill with a fever, mild lethargy and a rash. Her Road-to-Health-Booklet shows that all her EPI immunisations have been given. a) List SIX (6) common respiratory droplet spread viruses that might be transmitted between children in a day-care facility. (6) Samantha is taken to a doctor who finds enlarged, tender sub-occipital and post-auricular lymph nodes and a generalised erythematous maculopapular rash. Her mother says that the rash started on her face. Her temperature is 38.0 C. She does not have significant conjunctivitis, but there is a mild enanthem of small petechiae on her soft palate. The doctor informs her that rubella is the most likely diagnosis. b) How would you confirm the diagnosis of rubella? (1) c) List TWO (2) other possible differential diagnoses. (2) d) When can she return to the child day-care facility safely? (1) e) What are the risks for staff as well as the other children if she returns early? (2) f) Why do you think Samantha acquired this illness, despite being up to date with her immunisations? (1) g) List FOUR (4) features of congenital rubella syndrome. (4) Two months later, Samantha develops vomiting and diarrhoea. h) Why are respiratory and diarrhoeal diseases more common in preschool children who attend a child day-care facility? (2) i) List FOUR (4) common agents that she could have acquired at the child day-care facility that may have resulted in her gastro-intestinal symptoms. (4) Samantha is taken to her nearest clinic, examined and allowed to go home with oral rehydration solution and advice. No anti-emetics or anti-diarrhoeal agents are prescribed, which surprises her mother. j) Why must one be cautious about prescribing these medications to children? (2) k) List FOUR (4) ways in which the day-care facility could prevent the transmission of infections with enteric spread. (4) PTO/Page 6 Question 4 l)

6 6 Samantha s stool becomes bloody. She attends a local hospital, is examined, and admitted. She is pale, a little oedematous, irritable, febrile and ill. A full blood count (FBC) shows the following: Hb 6.8 g/dl, MCV 78, Plts 68 X 10 9 /L, WCC 8.3 X 10 9 /L. Renal function tests show: Urea 9.1mmol/L, Creatinine 155 µmol/l. A smear shows numerous schistocytes. l) What is the most likely diagnosis? (1) m) Name the TWO (2) specific bacterial organisms that commonly result in this disease. (2) n) What additional investigations could you perform to investigate the renal dysfunction? What results would you expect to find? (3) o) What antibiotic would you use to treat her dysentery while awaiting stool cultures? (1) Samantha s mother is anxious about further possible acquired illnesses and wishes to know if there are other vaccines to consider giving her child. p) Identify TWO (2) additional vaccines that you would recommend to Samantha s mother. Justify your selection. (4) Question 5 Sipho, a 9-year-old boy, presents to hospital complaining of shortness of breath. His mother informs you that Sipho, who has never had any previous medical problems, had flu-like symptoms last week but had seemed better this week. He played in a soccer match two days previously and since then has been short of breath, not able to sleep lying down and sometimes experiences a fast heart rate. On examination you find Sipho to be a well-nourished child. His skin feels cold and clammy. He has a heart rate of 190 beats per minute, a respiratory rate of 40 breaths per minute and a decreased capillary refill time. You do not have a blood pressure cuff so cannot measure his blood pressure. His jugular venous pressure is elevated and his right upper quadrant is tender although a liver cannot be palpated. On examination of his precordium you find a diffuse apex beat in the 6 th intercostal space in the anterior axillary line. There is no parasternal heave or palpable pulsations. On auscultation you hear distinct heart sounds but no murmurs and no extra sounds. a) List FOUR (4) causes of a large silent heart. (4) b) For each cause given in a) give the clinical features that will distinguish them from the other causes. (4) c) Based on the information above, what is Sipho s most likely diagnosis? (1) d) List THREE (3) non-haematological investigations you would like to perform and the expected results in this case? (6) e) Would you administer a fluid bolus to Sipho? Justify your answer. (2) f) What other treatment would you administer to Sipho? (6) PTO/Page 7 Question 5 g)

7 7 Although Sipho improves from this initial presentation he becomes chronically debilitated. He requires home oxygen and over the next three years has recurrent admissions to hospital for acute exacerbations of his disease. Shortly after his 12 th birthday he is once again admitted to hospital. On examination he is short of breath, wasted, has chest deformities and is barely able to walk from the bed to the bathroom. In a moment when his mother steps out of the room he tells you that he is tired of all the treatment and wishes to stop all therapy and be allowed to die. g) What are the principles of children s rights that you will consider at this point? (3) h) Which law governs your actions from here on? (1) i) Does the law allow for Sipho to make this decision without his mother s consent? Justify your answer with reference to the law mentioned above. (3) j) What is your responsibility in this case? (4) A decision is made by the relevant role players not to continue curative treatment. k) List FIVE (5) principles of palliative care. (5) l) Which drug would be most effective in relieving the symptom of shortness of breath in this case? (1)