THE COLLEGES OF MEDICINE OF SOUTH AFRICA. Examination for the Diploma of Child Health of the College of Paediatricians of South Africa.

Transcription

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 17 March 2015 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) The diagnosis and management of severe childhood malaria. (10) b) The introduction of the human papilloma virus (HPV) vaccine to the South African expanded programme of immunisation (EPI) schedule. (10) c) Child health surveillance in the context of developmental screening at district clinic level. (10) d) Accident prevention in the home in the under 2-years age group. (10) 2 Write short notes on a) In terms of the South African Children s Act of 2005, discuss when a child can give consent in each of the following situations i) Consent to medical treatment and surgical operations. ii) HIV testing. iii) Disclosure of HIV/AIDS status. iv) Contraception. v) Termination of pregnancy. (10) b Key actions needed to improve the quality of neonatal care in Sub-Saharan Africa. (10) c) The evaluation of and pharmacological treatment strategies for persistent pain in children with medical conditions. (10) d) The clinical presentation and management of organophosphate poisoning in children. (10) 3 Write short notes on a) An approach to a child with a red eye. (10) b) The diagnosis and management of seborrhoeic dermatitis in infants. (10) c) The problems of an infant whose mother has diabetes in pregnancy. (10) Please answer question 3 d) in a separate booklet d) End-of-life care planning for children with life limiting conditions. (10) 4 Write short notes on a) Clinical features of normal puberty in girls and boys. (10) b) An approach to a child with short stature. (10) c) The management of status epilepticus in a 3-year-old patient. (10) d) Pneumococcal vaccination in children. (10) 5 Write short notes on a) i) The pasteurisation of breast milk. ii) Donor breast milk and breast milk banks. (10) b) Neonatal hypoglycaemia and its management. (10) c) Social grants currently available for children in South Africa. (10) e) Oxygen therapy in the management of newborn infants. (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 18 March 2015 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 precise. 4 You may answer the questions in Afrikaans, if you wish. Question 1 Ryan is a 4-year-old male child, who is brought to the Community Clinic with swelling of his face, legs, his scrotum, and abdomen. According to his mother, she noted that this developed over two days. He had no fever. On examination the attending doctor noted the oedema, associated with conjunctival pallor. The blood pressure was 97/45mmHg, with a normal heart rate and respiratory rate. a) What FOUR differential diagnoses would you consider in a 4-year-old child with a similar presentation, and motivate for each? (8) Sister Nkosi tests Ryan s urine and notes that it appears to have a normal colour, and informs the doctor, that the urinalysis showed ph 7.0 Protein 4+ Blood 1+ b) What is the most likely clinical diagnosis? (1) c) List THREE appropriate blood or urine investigations you could perform, to support this diagnosis. (3) d) List FOUR appropriate blood investigations you would choose to perform, to try to elucidate the aetiology for this suspected clinical diagnosis. (4) PTO/Page 2 Question e)

4 e) Outline your initial management including nursing instructions (excluding blood tests) and possible specific treatment (6) The day after admission, Ryan develops abdominal tenderness, with vomiting and fever. Bowel sounds are reduced. There is rebound tenderness. f) What diagnosis would you now suspect in Ryan, with these new clinical symptoms and signs? (1) g) What treatment would be appropriate for this acute problem? (2) h) List THREE other complications that may occur in association with the primary clinical diagnosis. (3) i) Briefly discuss the pathophysiology for EACH of the complications you listed in (h). (6) The swelling and abdominal symptoms resolve on your therapy, and the urine abnormalities normalise. An ultrasound of the abdomen was reported as being normal previously. Ryan is discharged after two weeks. At a follow up visit in 4 weeks however, his mother says he still has facial swelling in the mornings, and the urine again shows 2+ protein. His blood pressure is still normal. Ryan is referred for a renal biopsy. j) List the TWO commonest histological patterns on renal biopsy that one would anticipate in children who present with the clinical scenario like Ryan s. (2) k) Discuss the prognosis of ONE of these histologic patterns, with Ryan s parent. (4) Question 2 John, a 5-year-old boy, presents to you with sudden onset of progressive weakness of the legs and inability to walk unaided. Apart from a respiratory infection 2 weeks ago, John has been a healthy child with no previous hospital admissions, and his immunisations are up to date. There is no history of trauma, seizures, severe headaches, fever or rash. There is no significant family history. They live on a farm. a) Give FIVE differential diagnoses. (5) The only abnormal finding on examination is symmetrical weakness of both legs with absent deep tendon reflexes. b) What is the most likely diagnosis and how will you confirm this? (5) c) How will you manage John further? Include all components of your management plan. (10) You are the medical officer on call, and the nursing staff call you to review John later that night as they are worried that his muscle weakness is progressing. d) Name TWO potential life threatening complications you need to look for. (2) e) List FIVE clinical signs signifying the need for intensive care and/or intubation. (5) Fortunately, John has none of these signs on examination. PTO/Page 3 Question 2f)

5 John s mother however is quite anxious. She wants to know what caused the disease. f) Briefly outline your discussion with her. (4) John s mother also wants to know what the prognosis is of the disease: will John make a full recovery and how long will it take? g) Briefly provide the information she seeks. (3) h) Name THREE other conditions that need reporting/notification that are included in the South African Expanded Programme on Immunisation (EPI). In EACH case provide the case definition. (6) Question 3 Thando is a 9-year-old boy who has recently relocated from another province and has never been to school. His mother reports that the primary schools have all refused to accept him because he is not suitable for placement in mainstream. She has brought Thando to hospital in the hope of receiving some assistance with a medical diagnosis and school placement. On history taking she reports that he was born prematurely at 28 weeks with a low birth weight of 1050g. He did not require ventilation but was treated for sepsis. As a young child he had no serious illnesses but was treated frequently for middle ear infection. His motor milestones were appropriate but his speech was delayed. He spoke his first words at 2 years. Thando can now speak in short sentences but his speech is difficult to understand a) What other elements of history would you consider important in a child with developmental concerns? (5) b) Describe the developmental milestones a 2-year-old child should have achieved in terms of the relevant domains being assessed. (10) The physical examination of the child is essentially normal; the external auditory canals appear normal but you are unable to see the tympanic membranes. You manage to arrange a hearing (audiology) test which reported as below. PTO/Page 4 Question 3c)

6 c) Interpret the findings of the hearing test. (4) d) How would you explain to the diagnosis to the parents? (3) The parents are concerned about the potential causes of this abnormality in their child. e) List THREE potential aetiological factors that are present in this child. (3) f) List the appropriate elements of further management of this child. (5) The family is unwilling for the child to be enrolled in school due their previous unpleasant experience with the school system. g) Explain how you would counsel the parents with regards to schooling and the rights of children in South Africa. (2) h) List THREE educational options that are available for this child in South Africa. (3) i) Discuss your approach to surveillance and prevention of this health problem among children. (5) Question 4 Bianca is a 10-year-old girl. She is admitted via casualty to your ward with a depressed level of consciousness, deep, sighing respiration, shock and severe dehydration. Her airway is patent. The Casualty Officer has made an assessment of diabetic-ketoacidosis (DKA), and initiated the correct management. Her blood sugar level on arrival was 29mmol/l. Her parents are distraught. This is the first time this has ever happened. a) What important factors in Bianca s history would suggest a diagnosis of diabetes mellitus? (3) PTO/Page 5 Question 4b)

7 You examine Bianca. Her height is normal and her estimated weight is almost on the minus 2 z-score line. She is no longer shocked, but is severely dehydrated. While examining her, the nurse has done some bedside tests. b) Name TWO other important tests that should be done and monitored. (2) The Casualty officer sent blood to the laboratory for a number of tests. You need to check that the request is correct and complete. c) Tabulate the FIVE most important laboratory tests and give a reason for each test. (10) While waiting for the results of the laboratory investigations, you need to check that the correct management has been initiated. d) Tabulate FOUR critical DKA-associated abnormalities (clinical and/or biochemical) that need to be carefully assessed and managed, indicating the core principle of management for each. (8) Bianca responds well to her DKA management over the next 36 hours, and is ready for transitioning off intravenous therapy. e) List the types of packaged insulin available for injection. (3) f) Based on the types of insulin available, briefly describe TWO possible dosing regimens and how you would decide which regimen to use giving reasons for the option chosen. (4) Before going home, you need to explain to Bianca and her parents the cornerstones of diabetes management at home. g) List FOUR of these, briefly describing for each the management approach. (8) DKA is a serious complication of T1 DM, and should be avoided. h) List TWO risk factors for a DKA recurrence in Bianca (2) Question 5 Karabo, a 9-month-old infant, is brought by her mother to the primary care clinic. The mother reports cough and difficulty breathing over the last 7 days. She is able to drink and is not vomiting. She had not had convulsions and is not lethargic. Karabo has fast breathing but no chest in-drawing, stridor or wheeze. She does not have diarrhoea, fever or an ear problem. a) How would you classify this child according the Integrated Management of Childhood Illness (IMCI) guidelines? (2) b) Briefly discuss how you would manage Karabo s respiratory complaint at clinic level. (5) PTO/Page 6 Question 5c)

8 In Karabo s Road to Health Book (RTHB), Karabo s growth curve shows unsatisfactory weight gain. She has very low weight for age and her weight-for-length z-score (WLZ) is < -3. There is no oedema. There is some palmar pallor and her haemoglobin is 9 g/dl. c) How would you classify Karabo's nutritional status? (2) d) With reference to the IMCI, how does this classification change the category of severity of her condition? (2) e) Briefly discuss how you would manage Karabo in light of this additional information. (5) f) Briefly discuss how you would manage Karabo s anaemia. (2) Karabo s mother tested HIV positive in pregnancy and has been on antiretroviral therapy (ART) since 26 weeks gestation. Karabo had a negative HIV PCR test at 6 weeks of age. She continued to breast feed until 6 months of age, when her mother was advised to stop breast feeding because she is HIVinfected. g) How would you classify for HIV infection in the child (according to IMCI) and is there anything more that needs to be done in this regard? (3) h) Do you suspect that she may have symptomatic HIV infection? Explain your answer. (3) i) What would place Karabo at risk of tuberculosis (TB) and what steps could be taken to minimise this risk? Explain your answer. (3) j) How could you assess Karabo for TB at clinic level? (3) Karabo was last seen at the clinic and immunised at 14 weeks. k) According to the South African Expanded Program on Immunisation (EPI), which vaccines are due now? (2) l) Briefly discuss the dietary advice that you would you offer Karabo s mother for her infant. (3) m) Briefly discuss all the other key issues, apart from immunisation and diet that should be covered at this clinic visit. (5)