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

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DCH(SA) THE COLLEGES OF MEDICINE OF SOUTH AFRICA Incorporated Association not for gain Reg No 1955/000003/08 Examination for the Diploma in 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 1955/000003/08 Examination for the Diploma in Child Health of the College of Paediatricians of South Africa 1 September 2011 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, 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 14-month-old child with moderate ( some ) dehydration. (10) b) The treatment regimen for an uncomplicated case of pulmonary tuberculosis in children.(10) c) What you would include in a breastfeeding policy for your hospital. (10) d) The aetiology and management of recurrent lower respiratory tract infections in an infant who has already experienced three such episodes. (10) 2 Write short notes on a) The management of a 6-month-old infant with eczema. (10) b) Factors that would make you suspect child abuse. (10) c) The differential diagnosis and main clinical features of a child with acute flaccid paralysis. (10) d) i) Why a disease should be notified. (3) ii) The process of notification. (3) iii) List 4 notifiable conditions, including one non-communicable condition. (4) 3 Write short notes on a) Interventions to reduce morbidity and mortality from diarrhoeal disease in a rural community. (10) b) Osteomyelitis in childhood. (10) c) The management of a teenager who presents with a depressed level of consciousness and history of alcohol ingestion. (10) d) The investigation and management of a urinary tract infection. (10)

2 4 Write short notes on a) Strengths and weaknesses of the new Road-to-Health Booklet. (10) b) Triage of children under 5-years of age presenting with medical emergencies at hospital emergency (casualty) units. (10) c) Child Health priorities in South Africa. (10) d) Conducting a successful paediatric mortality and morbidity meeting. (10) 5 Write short notes on a) The prevention and treatment of paraffin poisoning. (10) b) A 15-month-old child who has a head circumference below the -3 z-score line is hypertonic with increased reflexes in all limbs and cannot sit. Discuss your approach to further investigation and management. (10) c) Pneumococcal conjugate vaccination. (10) d) The prevention and social consequences (for the affected child) of foetal alcohol syndrome. (10)

3 THE COLLEGES OF MEDICINE OF SOUTH AFRICA Incorporated Association not for gain Reg No 1955/000003/08 DCH(SA) Examination for the Diploma in Child Health of the College of Paediatricians of South Africa 2 September 2011 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 Sipho is 2-years-old and has had a runny nose and a slight cough for a few days. This evening he developed a loud dry (barking) cough and his mother says he makes a funny" harsh noise when he breathes. The sound is heard during inspiration. a) What is the medical term for the noise? (1) b) What is the most likely cause? (1) c) List FOUR possible causes for this sound. (4) d) Describe the usual grading system used to assess the severity of this condition. (4) e) How would you manage Sipho at this stage? (3) An hour later you notice that the harsh breath sound is now also heard in expiration. f) How would this change your management? (3) Two hours later you are called by the nursing sister looking after Sipho. She informs you that he looks blue to her. g) What is the possible reason for this? (2) h) How will you manage Sipho at this stage? (5) i) Briefly indicate any complications that may arise. (2) A colleague asks you whether epiglottitis is a possible diagnosis. j) Discuss the clinical manifestations of a child with epiglottitis. (4) k) What is the aetiological agent in epiglottitis? (1) l) Discuss the role of X-rays in assessing a child with upper respiratory tract obstruction. (3) The patient s aunt has a 2-month-old baby. She brings the baby to you because he also makes a harsh noise when he breathes. It is heard in inspiration and the infant is otherwise well. m) Discuss your clinical assessment of this infant. (3)

4 n) What is the most likely diagnosis? (1) o) How can you confirm this diagnosis? (1) p) What advice would you give the aunt? (2) Question 2 Nonhlanhla, a 12-month-old infant is brought to your clinic because she has a fever, skin rash, loose stools and is refusing feeds. You confirm a temperature of 38.6 o C and she weighs 8.8 kg; clinically she is not dehydrated and has a morbilliform rash on the face and trunk, bilateral conjunctivitis and mild respiratory distress but a clear chest. You suspect that she has measles. a) What is the case definition of measles? (4) b) What investigations will help confirm your suspicion? (2) c) What is the incubation period and the period of infectivity of measles? (2) d) List THREE common complications that you need to watch for? (3) e) List THREE groups of children who have an increased risk of measles mortality. (3) f) How would you manage Nonhlanhla? (5) g) How would you manage Nonhlanhla s contacts? (4) On inspection of Nonhlanhla s Road-to-Health Booklet you discover that she was born prematurely at 33 weeks gestation with a birth weight of 1.6 kg and no recorded problems in the neonatal period. She has only been vaccinated at 6 and 10 weeks. She is able to crawl but is not yet standing or able to walk. h) How does the fact that she was preterm affect her vaccination schedule? (2) i) How would you address her incomplete vaccination status? (3) j) i) How does her preterm status influence the assessment of her developmental milestones now and in the future? ii) How would you categorise her development? (3) k) i) How does her preterm status influence the assessment of her growth now and in the future? ii) How would you classify her growth? (3) Your investigations confirm that Nonhlanhla has measles. Over the next few weeks you see a further 22 patients with suspected measles. The age distribution of these cases reveals three peaks as follows 6 12 months 4 cases 1 5 years 7 cases years 6 cases l) Explain each of these peaks. (3) m) How would you manage this outbreak of measles? (3) Question 3 Calvin is an 18-month-old boy brought to a district hospital emergency department one evening with a fever and cough for 3 days. He has neither diarrhoea nor any ear problems. You are the doctor on duty called to assess the child. a) List the IMCI danger signs that will need to be assessed. (2) You assess Calvin as having no danger signs. His weight is 8 kg. He has some palmar pallor but no oedema. His mother has not brought the Road-to-Health Booklet but she tells you that Calvin weighed 3.5 kg at birth. His expected weight for age is 11.6 kg. b) Comment on his current weight for age. (2)

5 c) Briefly describe your further assessment of Calvin s nutritional status. (5) d) Briefly outline your approach to the management of his nutritional status. (5) Calvin s mother informs you that his father has been on TB treatment for the past two months. She says that Calvin was tested for HIV and the result was negative. e) In the light of the above, what additional information would you obtain from the mother? (2) You determine that Calvin is breathing at 48 breaths per minute. He has no chest in-drawing or noisy breathing. f) How would you classify Calvin s cough using the IMCI approach? (4) It is almost midnight and you decide to admit Calvin. g) What is your immediate overnight management plan? Give reasons. (5) In the morning, you review Calvin s response and management plan. h) What is your differential diagnosis and indicate the most likely diagnosis? (3) i) What further investigations will you perform and how will you manage Calvin? (9) After Calvin improves on your treatment plan, you consider discharging him from hospital. j) What would you check as you prepare for Calvin s discharge? (3) Question 4 A young child, hidden by a parked vehicle, runs across a township road chasing a ball that his friend kicked. The driver of a motor vehicle, travelling at 70 km per hour, sees the child but does not have time to react and brakes too late. The vehicle knocks down the child. A paramedic team arrives at the accident site within 15 minutes. They notice the child lying motionless just off the side of the road. a) What should the paramedic team s first steps be in the assessment of this child? (3) It is established that the child is 5-years-old. His name is Jonas. His pulse is 122/min and weak, blood pressure 78/55, respiratory rate 19/minute, temperature 36.5 C. Capillary refill is delayed (>2 secs). His pulse oximeter oxygen saturation is 86%. There has been profuse scalp bleeding. There are multiple abrasions on his face, chest, abdomen and extremities. b) What FOUR priority interventions are needed? (4) Following the administration of emergency interventions the child s neurological status is assessed. Jonas is making incomprehensible sounds, withdraws from a painful stimulus and opens his eyes when this painful stimulus is administered. His pupils are both dilated and reacting asymmetrically and poorly to light. c) What rapid method for assessing Jonas consciousness level can be used at the road side? List the categories. (3) d) What alternative method could be used to assess the consciousness level? (1) e) What is Jonas s consciousness level (using either method)? (1) f) How would you interpret Jonas s level of consciousness score, i.e. what is its significance? (1) g) Should Jonas be moved further off the roadside and onto the pavement? If so, what precautions are necessary? (1) An intravenous line is inserted and fluids commenced

6 h) What type of fluid should be given? How much fluid should be given, and over what period? (3) i) What TWO physiological parameters are most important to monitor, if possible, during the transfer and thereafter (that have prognostic and therapeutic implications)? (2) Jonas is transferred to hospital by an ambulance once initial resuscitation is complete. During the transfer, Jonas is noted to be hypoxic and bag and mask ventilation is commenced. On arrival at the hospital Jonas is intubated. j) What route should be used for the intubation, and why? (2) k) What TWO x-ray films would you most like to see? Indicate TWO possible abnormalities you will specifically be looking for in each x-ray study. (4) l) Can Jonas be provided with analgesics and sedatives? Explain. (2) m) Following a traumatic head injury, the brain may experience primary or secondary brain injury. Explain what is meant by these two terms and indicate their timing (when it occurs). (5) Twenty-four hours after admission, Jonas remains obtunded, with irregular respirations, bradycardia, and hypertension. He also has neurogenic posturing and seizures. n) What are these signs indicative of? (1) o) What is the main risk of this complication? (1) p) List one intervention each related to the (i) child, (ii) driver, (iii) environment, and (iv) motor vehicle that could have prevented this accident occurring (i.e. primary prevention). (4) q) List ONE secondary prevention measure that could have reduced Jonas injury severity. (1) r) What is the leading cause of non-natural or injury death to children up to the age of 15 years in South Africa? (1) Question 5 Mrs Nabe was expected to deliver a very small infant. You (the paediatric medical officer) were requested to attend the delivery to take care of the newborn. After a normal vertex delivery the newborn takes a few gasps as he is gently dried with a warm towel, but when placed under the infant radiant warmer he stops breathing. You note he is floppy, pale, unresponsive to stimulation and has a palpable umbilical pulse of 60 beats per minute. a) What is the most likely cause for the apnoea? (1) b) What is the Apgar score of the infant and what should your response be? (2) c) What is the most likely pathophysiological cause for the bradycardia? (2) d) Outline all the next steps that might be required in the basic resuscitation of the neonate. (7) e) Comment on the concentration of oxygen you would use in the resuscitation of this newborn. (2) You are successful in your resuscitation. Within 5 minutes the infant is pink centrally (a bit blue peripherally) with good respiratory effort. He cries weakly to stimulation, moves his limbs spontaneously and has a pulse rate of 140/min. He weighs 1.2 kg. His gestational age is estimated to be 34 weeks. f) What is his Apgar score now? (1) g) Classify his weight and gestational age. (2) h) In view of his size and gestation, outline your management plan for the next 24 hours. (5) The infant does well in the neonatal nursery for the first 5 days, but on the 6 th day his abdomen becomes distended and he starts to return gastric aspirates which are greenish in colour. He passes a small amount of stool with some bloody mucous on the surface. You assess him clinically as having necrotising enterocolitis. You order an abdominal x-ray (supine and lateral decubitus) and draw blood for a full blood count and C reactive protein test.

7 i) List 3 signs on the abdominal x-ray that would provide strong supportive evidence of NEC. (3) j) His clinical condition and blood tests suggest septicaemia and his x-rays confirm necrotising enterocolitis with no signs of perforation. He is not shocked, not hypoglycaemic, not hypothermic nor hypoxic tabulate your management plan. (6) The hospital infection control manager approaches you and asks, in view of this being a possible hospital acquired infection, what could have been done to prevent the condition occurring in the infant. k) Tabulate THREE factors that place a newborn at risk of acquiring NEC and TWO interventions for each risk that you would consider using in the maternity/neonatal unit to minimise the risk of NEC. (9)

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 DCH(SA) Examination for the Diploma in Child Health of the College of Paediatricians of South Africa