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 21 August 2012 Paper 2 Short note type questions (3 hours) Instructions 1 Answer each of the following FOUR (4) questions in separate books. 2 Each question has 5 sub-questions. Answers to each sub-question should be approximately words (not more than 1 page) in length. 3 Each question is worth 50 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) The management of a child with dog-bites. (10) b) Childhood enuresis (10) c) Acute flaccid paralysis. (10) d) The diagnosis of infective endocarditis. (10) e) Recurrent childhood headaches. (10) 2 Write short notes on a) Factors affecting the poor uptake of vaccines in South Africa. (10) b) Hypertonic dehydration. (10) c) The prevention of childhood drowning. (10) d) Using Mortality Data to improve the health of children. (10) e) The tuberculin skin test (TST). (10) 3 Write short notes on a) Haemorrhagic disease of the newborn. (10) b) Teenage acne vulgaris. (10) c) Parental responses to having a baby with a congenital abnormality (e.g. cleft lip) and appropriate health care worker responses. (10) d) The Baby Friendly Hospital Initiative (BFHI). (10) e) Childhood grants currently available in South Africa. (10)

2 4 Write short notes on a) The management of acute severe childhood asthma. (10) b) The laboratory diagnosis of acute bacterial meningitis. (10) c) The airway management of a child with suspected head injury. (10) d) Notifiable medical conditions. (10) e) The infant of a diabetic mother. (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 22 August 2012 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 Mary, a 10-year-old girl, is admitted to a public sector regional hospital with hyperglycaemia. You diagnose type 1 diabetes mellitus. a) List 4 symptoms Mary is likely to have experienced in the preceding weeks. (4) She is restless and confused, her respiratory rate is 35/minute, her heart rate is 120/minute and she has a capillary refill time of 3 seconds. Her urine contains 4+ ketones. Initial laboratory findings include: Sodium 138 mmol/l Potassium 6.0 mmol/l Chloride 109 mmol/l Bicarbonate 8.0 mmol/l Urea 6.7 mmol/l Blood glucose 29 mmol/l You diagnose diabetic ketoacidosis (DKA). b) Describe the initial emergency assessment and management that you would offer Mary.(5) c) Calculate and interpret her anion gap. (2) She responds to these interventions and you plan her further management. d) Discuss the role of each of the following in the management of DKA

4 i) Insulin. (3) ii) Potassium. (2) iii) Sodium Bicarbonate. (2) After 6 hours her blood glucose is 8.0 mmol/l, and her urine contains 3+ ketones. e) How would you alter her management now? (2) After her initial improvement she becomes drowsy and less responsive. Her blood glucose is 10.0mmol/L. f) Describe 2 methods you could use to assess her level of consciousness. (4) g) What is the likely explanation for her clinical deterioration? (1) h) How would you manage this complication? (4) She recovers from her DKA and is started on maintenance insulin therapy. i) Design a maintenance insulin regimen that you believe would be suitable for her. (4) Her diabetes is well controlled for the next 3 years and then deteriorates. j) Discuss the difficulties in managing chronic medical illnesses during adolescence. (3) k) Name 1 long term complication of type 1 diabetes mellitus. (1) l) How would you prevent this complication from developing? (1) m) How would you screen for this complication? (2) Question 2 Sifiso, a 5-month-old boy, accompanied by his mother Thelma, is admitted to a district hospital. He was born at home and this is his first encounter with the health care system. a) What immunisations should Sifiso have received by 5 months of age? (5) Clinical examination reveals Wasting Stunting Oral candidiasis Generalised lymphadenopathy Tachypnoea Inter & subcostal recessions Scattered bilateral crackles Pulse oximetry is 80% while breathing room-air, but improves to 90% when oxygen via nasal cannulae is administered. You diagnose community-acquired bronchopneumonia. b) List 4 likely bacterial causes for his pneumonia. (2) c) List 4 likely viral causes for his pneumonia. (2) d) What 4 investigations would you request? (4) e) For each of these indicate the clinical relevance of their results. (4) f) Discuss Sifiso s management over the next 24 hours. (7)

5 You are concerned that Sifiso may be HIV-infected. g) How would you confirm this? Provide an explanation for your choice of test(s). (4) Thelma refuses HIV-testing for both Sifiso and herself. h) Discuss the implications of her decision under the following headings, and indicate how you would address each of the issues raised i) Clinical. ii) Ethical. iii) Legal. (12) Question 3 Nosipho is 41 weeks pregnant and presents to a district hospital with a history of reduced fetal movement for the past 3 days. Profound fetal bradycardia is detected and plans for an emergency Caesarian Section are initiated. a) Discuss what you will do while awaiting delivery of the baby. (4) The baby is delivered and is pale, hypotonic, apnoeic and bradycardic (HR <60/minute). b) Discuss the first 10 minutes of your resuscitation of this child. (8) Following 10 minutes of resuscitation, the baby has a heart rate of 120/min, has intermittent gasping respiration and is still hypotonic. c) What 2 immediate complications could you anticipate? (2) d) How would you manage each of these complications? (4) You diagnose perinatal asphyxia. e) How would you clinically distinguish moderate from severe perinatal asphyxia? (4) f) What is the long term prognosis of each? (2) g) You consider referring the baby to the nearest tertiary neonatal centre. How would you decide if this newborn warrants referral? (3) h) How would you stabilise the baby prior to referral? (5) A few weeks later the child is well enough to be discharged. i) List 8 potential long term complications of perinatal asphyxia. (8) Question 4 Molly, a 1-year-old girl presents to the Casualty department with a history of a single seizure which lasted 5 minutes. Her parents report she had a fever at the time of the seizure and has had flu. You diagnose an upper respiratory tract infection with associated febrile convulsion. a) Define a simple febrile seizure. (5) Molly s parents have a number of questions; outline your answer to each

6 b) Is she going to have another seizure? (2) c) Is she going to develop epilepsy? (2) d) Can we prevent her from fitting the next time she has a fever? (2) e) What must we do if she fits again? (2) f) Will she be able to go to a normal school? (2) g) Should we start giving her an anti-convulsant? (2) h) Are you going to need to do any tests on her? (3) You finish answering their questions and are called to reassess Molly. She has started convulsing again. You notice a generalised tonic-clonic seizure that lasts for 45 minutes. You diagnose status epilepticus. i) Describe the emergency management of status epilepticus. (10) j) Name 2 medications used for the long-term treatment of epilepsy. (2) k) For each of these, discuss potential adverse effects and their detection and management. (8) Question 5 Themba, a 15-month-old boy presents to a regional hospital with a 5 day history of vomiting and diarrhoea. a) Compile a list of differential diagnoses for Themba s vomiting and diarrhoea. (5) b) What advice would you provide Themba s mother to prevent recurrence of his diarrhoea? (4) c) What advice would you provide Themba s mother on what to do if his diarrhoea does recur? (4) You examine Themba and find that he is alert and well-hydrated. You also detect jaundice and hepatomegaly. d) List 5 potential causes for Themba s condition. (5) e) What 4 bed-side investigations would you perform? (4) f) How would each of these assist you in caring for Themba? (4) g) Identify 4 laboratory investigations you would perform and provide a rationale for each one. (8) Themba recovers well and 6 months later is brought back to the hospital. His parents are planning a 2 month visit to Mozambique; they will be leaving in 2 weeks and would like advice on malaria prevention. h) Discuss malaria prevention in a 2-year-old. (6)