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

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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

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 3 September 2008 Paper II (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. Question 1 Write short notes on a) The pathophysiology and management of physiological jaundice of the neonate. (10) b) Major developmental milestones at 18 months of age, under the headings a. Gross motor/locomotion b. Fine motor/manipulation c. Language/communication d. Personal/social aspects (10) c) How you would perform a lumbar puncture in a 6-month old infant. (10) d) Advice you will offer a parent who complains that her 3-year-old child won t sleep. (10) PTO/Page 2 Question 2

2 Question 2-2- Write short notes on a) When lymph nodes should be considered abnormal in children. (10) b) The diagnosis of acute rheumatic fever. (10) c) The inheritance of Duchenne s muscular dystrophy. Draw the family tree of a mother who is a carrier of the abnormal gene. (10) d) Sedation for painful procedures in children. (10) Question 3 Write short notes on a) The prevention of malaria in young children. (10) b) The management of near-drowning. (10) c) Your approach to a three year old child with constipation. (10) d) Respiratory syncitial virus infection under the headings: clinical features, diagnosis, treatment and prevention. (10) Question 4 Write short notes on a) Community-based antenatal interventions that could potentially improve birth weight and prevent prematurity. (10) b) The management of petrochemical poisoning (paraffin) and the safety advice you would offer a mother to help her prevent this from happening.. (10) c) The immunization of adolescents (illustrate with two examples). (10) d) Ready to-use-therapeutic-foods. (10) Question 5 a) Write short notes on foetal alcohol syndrome. (10) b) A 3-year-old child with vomiting and diarrhoea presents to the paediatric outpatient setting at a district hospital. The child is classified as having severe dehydration using IMCI guidelines. List the signs that will be present and outline the further management of this child. (10) c) Discuss factors that determine the use of child primary health care services by caregivers. (10) d) What is the Child Healthcare Problem Identification Programme (Child PIP)? Briefly describe how you would carry out this programme in your hospital? (10)

3 DCH(SA) Paper II I 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 4 September 2008 (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 One Marianne, a three-year-old girl, is admitted to your hospital with failure to thrive. Her mother is HIV positive and has recently been diagnosed with TB. a. Which test is indicated to establish whether Marianne is HIV-infected? If positive, do you need to confirm the result with another test? (2) A chest x-ray is taken, Mantoux tuberculin skin test done and nasogastric aspirates collected as part of the investigation for tuberculosis. b. List 5 possible radiological features on chest radiograph in children with tuberculosis. (5) c. Describe how a Mantoux skin test is done, and interpreted. (5) d. Name two other skin tests in use for the diagnosis of tuberculosis, and their role in the diagnosis of tuberculosis. (3) e. Marianne s Mantoux skin test shows no reaction. List 3 causes for a false negative tuberculin test. (3) f. Name two additional methods by which a sputum could be obtained from this child. (2) g. New blood tests for the diagnosis of tuberculosis are available. Describe the principle on which they work. (2) PTO/Page 2 Question 1 Continued

4 - 2 - Marianne s HIV test result comes back negative. The nasogastric aspirate shows acid fast bacilli. A diagnosis of pulmonary tuberculosis is made. h. Briefly discuss the management of Marianne s TB. (6) i. Marianne s mother asks whether her 1 year old son should be treated for TB as well. Describe your management of this sibling.. (4) j. List the elements of DOTS (Directly Observed Therapy Short course). (5) k. Discuss briefly whether BCG vaccination should have protected Marianne against the development of pulmonary TB? (3) Question Two Legae, a 4-year-old boy, is brought to the local hospital by his grandmother because she is worried about his difficulty with walking. She says that he falls easily and does not have good balance. His head circumference is 54cm (just above +2SD). There are no spinal abnormalities. Legae walks on his toes ( toe-walking ). There is increased tone and brisk reflexes in both lower limbs. Both feet are in equinus with limited dorsiflexion at both ankles. There is also some spasticity of the upper limbs, fair to good trunk and head control, and no bulbar involvement. Legae has delayed motor milestones and difficulty with fine motor skills. He has a non-paralytic squint (strabismus) and decreased visual acuity bilaterally. You diagnose Legae as having cerebral palsy. Further history is obtained from the Road to Health Card. Legae was born at 30 weeks gestation weighing 1.2 kg. His Apgar score was 8 at 1 minute, and 9 at 5 minutes. He was ventilated for two weeks. A neonatal cranial ultrasound showed intraventricular haemorrhage. a) Define cerebral palsy (CP). (2) b) What is the most likely cause for Legae s cerebral palsy? Provide at least TWO facts that support your conclusion. (2) c) How would you classify Legae s cerebral palsy? (1) d) What is the usual prevalence of CP in developed countries? (1) e) Provide a brief (one line) pathophysiological explanation for each of the following signs i) Head circumference just above +2 standard deviations of normal. (2) ii) Brisk lower limb reflexes. (2) iii) Toe-walking. (2) iv) Non-paralytic squint (2) f) Describe the process whereby an intraventricular haemorrhage leads to cerebral palsy. (2) PTO/Page3 Question 2 Continued

5 - 3 - g) List THREE other disabilities, associated with cerebral palsy, that Legae may have? (3) You assess Legae s speech. He is able to say approximately 50 words. He speaks in 2-3 word sentences. h) At what age (in months) would a child normally achieve this level of speech? (1) i) What single investigation may be most helpful in investigating Legae s speech delay? (1) j) List THREE further diagnostic or therapeutic interventions you would arrange for Legae, and their possible benefit of doing/offering each. (3) k) Indicate TWO goals of treating spasticity in a child with CP, i.e. what are you trying to achieve? (2) l) What grant is Legae eligible for? Why does Legae qualify for this grant? (2) m) Legae s granny wants him to attend the pre-school down the road. What will you advise her about this? (2) Legae s granny is keen for him to be given a new injection that helped another child in the township (with the same problem as Legae) walk better. She says it s called Botox. You promise her to find evidence that this therapy might benefit Legae. You find the following article during a Pubmed/Medline search. Botulinum toxin for spasticity in children with cerebral palsy: a comprehensive evaluation. Bjornson K, Hays R, Graubert C, Price R, Won F, McLaughlin JF, Cohen M. Pediatrics 2007 Jul;120(1): BACKGROUND: Spasticity is a prevalent disabling clinical symptom for children with cerebral palsy. Botulinum toxin provides a focal, controlled muscle weakness with reduction in spasticity. Interpretation of the literature is difficult because of the paucity of reliable measures of spasticity and challenges with measuring meaningful functional changes in children with disabilities. OBJECTIVE: This study documents the effects of botulinum toxin A (botox) injections into the gastrocnemius muscles in children with spastic diplegia. Outcomes are evaluated across all 5 domains of the National Centers for Medical and Rehabilitation Research domains of medical rehabilitation. These domains include pathophysiology, impairment, functional limitation/activity, disability/participation and societal limitation/contextual factors METHODS: A randomized, double-masked, placebo-controlled design was applied to 33 children with spastic diplegia with a mean age of 5.5 years and Gross Motor Function Classification System (GMFCS) Levels of I through III. Participants received either 12 U/kg botulinum toxin A (Botox) or placebo saline injections to bilateral gastrocnemius muscles. Outcomes were measured at baseline and 3, 8, 12, and 24 weeks after injection. PTO/Page4 Question 2 Continued

6 RESULTS: Seventeen participants were randomized to receive botox and 16 received saline injections. Decreases in the electromyographic representation of spasticity were documented 3 weeks after botox treatment (Mean QEK ± standard deviation (μv): botox -4.8 (±14.0), placebo 3.2 (±8.2), p=0.05) A significant decrease in viscoelastic aspects of spasticity was present at 8 weeks, and subsequent increases in dorsiflexion range were documented at 12 weeks for the botox group (Median left /right Ankle range of movement, botox -5.0 (±27), placebo 0 (±17), p=0.001) Improvement was found in performance goals at 12 weeks and in maximum voluntary torque and gross motor function at 24 weeks for the botox. There were no significant differences between groups in satisfaction with performance goals, energy expenditure, Ashworth scores, or frequency of adverse effects. The safety profile of 12 U/kg of botox was excellent n) List two MESH terms you would use to identify this (or a similar) study during a Pubmed/Medline search? (1) o) What study design was used? (1) p) What were the main study outcomes? (1) q) What is meant by a double-blind study (in the context of this study)? (1) r) Was the decrease in the electromyographic representation of spasticity documented 3 weeks after botox treatment statistically significant? Explain. (1) s) What statistical test would have been used to decide if this difference was statistically significant? (1) t) Was the increase in dorsiflexion range documented at 12 weeks for the botox group statistically significant? Explain. (1) u) Why was a median, rather than a mean used to describe the change in the dorsiflexion range? (1) v) What advice would you offer Legae s granny about the value of Botox for him? (2) Question Three You are working as a medical officer in the neonatal nursery of a large peri-urban regional hospital. The nursery has 26 beds, including 4 ICU and 6 high care beds, and caters for deliveries per annum, so the nursery is regularly overcrowded. The low birth weight rate is 21% and the perinatal mortality rate (PNMR) in the hospital is 46.3/1000. a) Define perinatal mortality rate. (2) b) Comment on the PNMR in your hospital. (1) c) What is the difference between the perinatal and neonatal mortality rate? (2) d) What is the significance of the two rates (i.e. what do they indicate) and what benefit can be derived from monitoring them both? (4) PTO/Page5 Question 3 Continued

7 - 5 - e) List THREE likely major causes of neonatal mortality at this hospital. (3) You recently noticed an increase in the number of cases of neonatal sepsis in your nursery with an associated rise in the mortality rate. You are concerned about nosocomial infections and wish to establish an infection control and surveillance system for the nursery. f) How do you define nosocomial infections? (2) g) Why is a neonatal nursery in a regional hospital a high risk area for nosocomial infections? (5) h) Describe, briefly how would you implement an infection control and surveillance system? (5) Your surveillance system identifies a cluster of Klebsiella infections and the hospital manager invites an outside investigation into the outbreak. The investigators report identify the following factors as contributing to this outbreak inappropriate admissions leading to overcrowding, understaffing and a breakdown in infection control practices. These have been compounded by contaminated feeds and the use of multidose vials in the nursery. You are asked to respond to the report. i) Tabulate the different categories of newborn babies in your hospital and identify what facilities you require for the accommodation and care of each category. (5) j) Which babies require admission to a neonatal nursery? (2) k) What basic infection control practices will you reinforce in the unit to reduce nosocomial Klebsiella infections? (5) l) How will you control the preparation and administration of milk feeds to reduce the incidence of contamination? (2) m) How do you suggest the use of multidose vials be optimised in the nursery? (2) Question Four Palesa, a 24-month-old girl, is brought to the clinic by her mother. The mother complains that she seems to tire easily and that she cannot run around for a long time before she has to rest - by sitting on her haunches (squatting). a) What else should you ask in the history to help elucidate the cause? (6) You proceed to examine Palesa and find that she is cyanosed and has an ejection systolic murmur audible over the precordium. b) What else would you look for as far as the cardiac examination is concerned? (4) PTO/Page6 Question 4 Continued

8 - 6 - You make a presumptive diagnosis of Tetralogy of Fallot c) What are the FOUR classical elements of the lesion? (4) d) List FIVE complications that may arise in children with this condition? (5) While you are examining her she becomes deeply cyanosed and squats on the floor. e) What do you call this phenomenon? (1) f) Discuss the pathophysiology of Palesa s a. Cyanosis. (2) b. Squatting episodes. (2) g) What can precipitate these episodes? (4) h) How do you manage them? (4) i) List four features that you expect to find on Palesa s chest xray (4) While you are examining Palesa you notice that she has severe dental caries. j) How are you going to manage this problem? (2) k) What is the implication of this to her future health care? (2) Question Five S bonelo, a 4-year-old boy, presents to hospital with a short history of swelling of the face and lower limbs. He was previously well. There is no history of previous medication and no family history of any similar illness. On examination he has periorbital and pedal oedema and ascites. His BP is 100 / 70 and there are no other signs of systemic disease. His urine dipstix shows blood trace, protein 3+, SG 1015, ph 6.0, no nitrates or leucocytes. a) What is the most likely diagnosis? (2) b) What THREE investigations will you do to confirm your diagnosis? (3) c) List THREE possible causes of this condition? (3) d) What is the one major differential diagnosis and tabulate how you will differentiate between these two conditions? (5) PTO/Page7 Question 5 Continued

9 - 7 - e) How will you manage S bonelo? (5) f) What dietary advice will you give to his mother? (2) g) Suggest THREE ways in which S bonelo s classification and prognosis may differ from Steve, a white boy with the same symptoms and primary diagnosis (3) After a few days in hospital S bonelo develops a fever and complains of abdominal pain. On examination you find rebound tenderness, guarding and reduced bowel sound. Abdominal X-ray shows dilated loops of bowel with air-fluid levels. h) What is your diagnosis? (2) i) What is the pathological significance of the: i) rebound tenderness (2) ii) reduced bowel sounds (2) iii) air fluid levels on the abdominal x-ray. (2) j) What is the most likely microbiological cause for this complication? (2) k) How will you manage the complication? (3) l) What TWO other complications can S bonelo s primary condition give rise to? (2) m) Once he has recovered, how would you prevent this complication in the future? (2)

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 Examination for the Diploma of Child Health of the College of Paediatricians of South Africa 19 August