FC Paed(SA) Part II

THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Final Examination for the Fellowship of the College of Paediatricians of South Africa 21 August 2012 Paper 2 Short note type questions (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer) Note to candidates: Each question is of equal value and should be completed in 45 minutes. You may answer questions in Afrikaans if you so wish. 1 a) Write short notes on the mechanism of action, and give TWO indications and ONE example for each of the following: i) Loop diuretic. ii) Thiazide diuretic. iii) Potassium sparing diuretic. iv) Osmotic diuretic. (10) Write short notes on the use of the following in clinical paediatrics: i) C- reactive protein (CRP). ii) Erythrocyte sedimentation rate(ESR). iii) Procalcitonin. iv) High sensitivity CRP. (10) Write short notes on the secondary causes of hypertension on childhood. (10) Define a cross sectional study and write short notes on the limitations of this type of study. (10) [40] Define acute disseminated encephalomyelitis (ADEM) and write short notes on the presentation of this condition. (10) Write short notes on the definition and causes of neonatal hypocalcaemia. (10) What are the causes and diagnostic features of the Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH)? (10) Write short notes on the cardiac causes of sudden cardiac arrest in children. (10) [40]

b)

c) d)

a) b) c) d)

Write short notes on a) The management of status epilepticus. (10) b) The intraosseous (IO) route for venous access. In your answer, address indications, suitable sites, equipment to be used and complications. (10) c) The management of the choking infant. (10) d) Weight estimation of children in emergency situations. (10)

[40] 4 a) There has been a recent resurgence in interest in school health in South Africa. Write short notes on the importance of school health and the services that should be provided by a school health system. (10) Write short notes on i) The Tshwane Declaration on breastfeeding. (4) ii) The Baby Friendly Hospital (6) Briefly discuss the reasons why some parents may refuse or are hesitant to have their child(ren) immunized. (10) Write short notes on the clinical features of suspected sexual abuse in children. (10) [40]

b)

c) d)

FC Paed(SA) Part II THE COLLEGES OF MEDICINE OF SOUTH AFRICA

Incorporated Association not for gain Reg No 1955/000003/08

Final Examination for the Fellowship of the College of Paediatricians of South Africa 22 August 2012 Paper 3 Theme based questions (3 hours)

All questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer) Note to candidates: There are 4 scenario based questions (1 - 4). All FOUR questions are to be answered. Each question to be answered in a separate book (or books if more than one is required for the one answer). Each question is of equal value (40 marks) and should be completed in 45 minutes. You may answer questions in Afrikaans if you so wish. QUESTION 1 Becky is a five week old female infant seen with a history of poor feeding and poor weight gain. Her mother has 5 other children. Beckys birth weight was 2,4Kg at 40 weeks. No problems are recorded on her road to health chart. Her current weight is 2,28kg. She has a sloping forehead and a prominent nose, slanting eyes and an unusually small chin; her ears are abnormal and tilted backwards and there is also clinodactyly of her fingers. Her resting heart rate is 156/min, respiratory rate 59/min and blood pressure 88/36 mm Hg. Percutaneous saturation in room air is 93%. On inspection, the praecordium is hyperactive and epigastric pulsation is observed. The apex beat is heaving and is situated in the 5th intercostal space in the anterior axillary line. A parasternal heave is also palpable. A grade 3/6 pansystolic murmur is heard over the whole praecordium and the second heart sound is single and loud. Over the apex, a soft mid-diastolic rumble is present. The liver is palpable 3cm below the costal margin and a tip of the spleen is palpable. She has a small anterior fontanelle and hip movement is limited. a) b) c) d) e) f) How would you explain Beckys growth pattern? Is there a haemodynamically significant cardiac lesion present? Motivate your answer. What complications of a cardiac lesion are present in this baby? Explain What is your differential diagnosis of the cardiac lesion? How would you differentiate pneumonia from cardiac failure in this infant clinically? How would you treat cardiac failure in this child? The nurse points out that the infant looks dysmorphic g) Apart from the trisomies, what is your differential diagnosis for Beckys dysmorphism? (4) (1) (5) (5) (4) (5) (4)

h)

How would you make the diagnosis if you did not have access to a geneticist? Investigations confirm trisomy 18 with a significant cardiac lesion

(4)

i) j)

What other problems would you expect in this child? What would your advice be regarding the further management of the cardiac lesion?

(4) (4) [40]

QUESTION 2 The obstetrician- gynaecologist working with your practice contacts you to discuss a client. A 23-year-old primigravida, Mrs. Plaatjies, presents with a clinical picture suggestive of rubella . She is currently 28 weeks pregnant. You are in a joint consultation with Mrs Plaatjies and her husband. a) b) c) d) e) f) g) To which family of viruses does rubella belong? (1) Give a basic description of the virus morphology (1) How can you confirm the infection in the mother? (3) You are asked to counsel the parents with regard to the risk of transmission throughout pregnancy and the risk of abnormalities in the infant. What would you tell them? (5) When is the highest risk for congenital defects to occur? (1) How can rubella be diagnosed in a fetus? (4) What is the difference between congenital rubella infection and congenital rubella syndrome? (3)

Infection with rubella is confirmed in Mrs. Plaatjies and the baby, named John, is delivered at term. h) i) j) k) Which features of congenital rubella infection would you assess John for at birth and in early infancy? Provide some information on the frequency of these features. (12) John has no features suggestive of infection. How will you asses him to confirm the presence of congenital rubella? (4) Congenital rubella is confirmed in John. For how long will he potentially be contagious? (1) What late manifestations should he be followed-up for? (5) [40]

QUESTION 3 You are consulted by the mother of Nkosi, a 3-year-old girl, who was born with an open lumbosacral myelomeningocoele involving segments L 2 to L5 and S1-S4. The defect was closed when she was 24 hours old and she stayed in hospital for one month after surgery due to complications. She is not able to walk and has not been managed appropriately. The family stay in a rural area and at the local clinic her mother was informed that the reason for her not being able to walk is due to the presence of her abnormal feet. She has not attended any specialist clinic since her discharge from hospital 3 years ago. Nkosis mother is the sole provider for the family, earning R100 000-00 per year. a) b) c) What factors play a role in the neurological fall out in children with spinal dysraphism? (5) What abnormal neurological signs are expected in this child? (7) What other clinical abnormalities may be present in children with spinal dysraphism? Describe the clinical findings associated with each system involved. (8)

d) e)

Describe the holistic long-term management of this child in the ideal situation including referral to specialist clinics/services and special investigations. (18) Does Nkosi qualify for a care-dependency grant? Motivate your answer. (2) [40]

QUESTION 4 Siphiwe, a four year old, is referred from the local clinic with a history of night sweats, loss of appetite and weight loss. Her immunizations are up to date. There is a history of close contact with a relative with tuberculosis (TB). a) b) c) Discuss what investigations you will do on Siphiwe to make a diagnosis of TB. In your answer, indicate the value of the investigations in establishing the diagnosis. (6) If Siphiwe does not have TB, does she need prophylaxis against TB? Explain your answer. (2) Name the three drugs used as first-line anti-tuberculosis therapy in children ( mark each), indicate the dose (1 mark each) and duration of treatment ( mark each), and mention ONE side-effect of each drug (1 mark each). (9) Give the definitions for multidrug-resistant tuberculosis (MDR-TB) and extensively drugresistant tuberculosis (XDR-TB). (3) Name TWO drugs used in treating MDR-TB and mention ONE side-effect of each.(2) Discuss five critical challenges in controlling MDR and XDR-TB. (10) Discuss co-treatment of HIV and TB. (4) Discuss consent for HIV testing in children in South Africa. (4) [40]

d) e) f) g) h)