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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 1 September 2011 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. The mark indicated in each subsection is an indication of the proportion of the mark for each question. Each 10 mark sub-question should be allocated about 11 minutes. You may answer questions in Afrikaans if you so wish. 1 Write short notes on the a) Management of the diabetes in a diabetic child who is an athlete (a child actively participating in competitive sport). (10) b) Clinical significance of caf-au-lait macules in children. (10) c) Mechanism of action, spectrum of activity, pharmacokinetics and side effects of quinolones. (10) d) Pharmacotherapy of attention-deficit hyperactivity disorder. (10) [40] Write short notes on a) The management of atopic eczema. (10) b) The clinical presentation and diagnosis of q22 gene deletion syndrome. (10) c) Adolescent vaccination with particular reference to human papilloma virus. (10) d) Strategies you would employ if asked to improve the transition of adolescent patients into an adult service. Consider interventions focused on the patients, the staff and the service. (10) [40] Write short notes on a) The differential diagnosis of syncope in the paediatric patient. b) The symptoms and signs of poisoning due to tricyclic antidepressant drugs. c) Feeding and swallowing difficulties in the HIV infected child. d) The fluid management of infants with severe hypernatraemic dehydration. Write short notes on a) Inhibitors to Factor VIII in a child with Haemophilia A. b) Causes of blindness and low vision in children. c) Clinical features of severe malaria in childhood. d) Management of ascites in a child with cirrhosis. (10) (10) (10) (10) [40] (10) (10) (10) (10) [40]

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 2 September 2011 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: Each question is of equal value and should be completed in 45 minutes. You may answer questions in Afrikaans if you so wish.

Question 1 Mrs Nomvulo Ncube lives in an RDP house in Umbilo, Kwazulu Natal. She and her husband are unemployed. They have two children, both of whom receive a child support grant. Mrs Ncube is pregnant with her third child. She tests HIV positive. She had no suspicion that she was infected. Her CD4 count is 550. a) Some experts believe that, for the sake of the baby, Mrs Ncube and women like her should receive full anti-retroviral therapy (HAART). Outline the content of current debates on this issue in the southern African context. (4)

Mrs Ncube does not receive HAART, but is put on to zidovudine (AZT) at 16 weeks of gestation. She has disclosed her HIV status to her husband. She asks your advice about breast feeding her baby. b) How would you counsel her? On what considerations is this based? (6)

Mrs Ncube goes into premature labour at 33-weeks of gestation and delivers a 1630g singleton girl before intrapartum anti-retrovirals can be given to her. c) Describe the risk of transmission of HIV to an infant in this situation. (3)

The baby is well grown for gestational age and does not manifest any complications of prematurity. Mrs Ncube has decided to exclusively breast feed her baby. d) Describe how you will ensure safe infant feeding for such an infant in the nursery. What prophylaxis against postnatal HIV transmission will you recommend and why? (6)

Despite having disclosed her HIV status to her husband, Mrs Ncube does not want her status to appear on the Road to Health Book PMTCT/HIV Information page.

e)

Discuss this situation from a Child Rights perspective.

(5)

Before discharge, Mrs Ncube asks your advice about immunisation of her child. f) i) ii) What schedule is required in the infants first 6 months of life? Describe any additional risks that immunisation might carry for this infant. (3) (3)

You have successfully enabled Mrs Ncube to exclusively breast feed while in the nursery. g) What is the best way that a health service should support Mrs Ncube in her feeding choice after discharge from hospital? What is the evidence for your answer? (6)

The baby is discharged on nevirapine. At 6-weeks an HIV PCR is done on the baby. It is negative. Breast feeding continues. h) i) ii) What are the implications of the negative HIV PCR at this stage? How should this infants HIV risk status be managed from here? (2) (2) [40]

Question 2 Siphiwe is born at a midwife obstetric unit at 41 weeks gestation. There was a prolonged second stage of labour but an ambulance only arrived just after he is born. The Apgar score is recorded as 2 at one minute and, after bag and mask resuscitation, 4 and 7 at 5 and 10 minutes respectively. a) According to current neonatal resuscitation guidelines, which three parameters should be assessed immediately after birth to decide whether resuscitation is needed? (3)

He is immediately transferred to a hospital with facilities to ventilate neonates. A blood gas done 45 minutes after birth shows: pH 6.90; pCO 2 40 mmHg (5.3 kPa); pO 2 90 mmHg (12 kPa); Base excess -22.5 mmol/L. b) Should this infant survive what would you expect the chances of a normal neurological outcome to be? Explain very briefly. (2)

Siphiwe is noted to have a depressed level of consciousness with an incomplete Moro reflex and a weak grasp. He has a focal seizure at 3 hours of age involving the left arm, but this is controlled with a loading dose of phenobarbitone. He is still breathing normally on his own and responsive to stimulation. A diagnosis of hypoxic-ischaemic encephalopathy (HIE) is made. c) d) e) Describe the various stages of HIE. In what stage would you place Siphiwe? What is the prognosis for each stage of HIE? (9) (1) (3)

Apart from general supportive care, a relatively new modality of treatment that has been shown to reduce mortality and disability, not available in most South African hospitals, could be considered for Siphiwe at this stage if the facilities were available. f) g) h) What is this modality of treatment? (1) Discuss briefly how it is thought to work (mechanism of action). (5) A meta-analysis of 4 trials with a total of 479 infants showed a reduction in combined outcome of death & mod-severe disability: RR 0.76 with 95% CI 0.65-0.88. What is the level of evidence that this modality of treatment is effective? Explain your answer. (2) The same meta-analysis reported that the number needed to treat was 6. Explain this. (1)

i)

At 12 hours of age, Siphiwe develops severe apnoea and requires intubation in order to resuscitate him. While still intubated, his parents arrive and the attending doctors have to discuss with them whether he would be admitted to the intensive care unit (ICU) for ventilation. j) What ethical principles should the attending doctors take into account when they consult with the parents on this matter and indicate how these principles may influence the decision as to whether Siphiwe should be admitted to the ICU? (8)

Siphiwe survives, is discharged after two weeks, and is followed up. At two years of age, significant handicap is present. k) Indicate what the most likely components of his handicap would be and relate this to the pathophysiology of a severe hypoxic-ischaemic insult in a term infant? (5) [40]

Question 3 Sipho is an 8-year-old boy. He has a history of recurrent respiratory tract infections and has been hospitalised five times in the past three years for pneumonia. In the last two years he has been treated for tuberculosis twice (two six-month courses), although the diagnosis of TB was not confirmed. On examination Sipho is thin and wasted. His respiratory rate is 45 breaths per minute. He is clubbed and has generalised lymphadenopathy but is not cyanosed. His oxygen saturation is 88% in room air. He has signs of a chronic chest condition and there are diffuse crackles throughout both lung fields. His breath is smelly. a) b) List 5 possible causes of Siphos chronic lung pathology. List 3 likely bacterial causes of his acute respiratory infection. (5) (3)

Sipho tests HIV positive. c) d) e) f) g) What other causes of Siphos acute respiratory infection should you consider, besides the 3 bacterial causes listed in b) above? (2) Discuss appropriate empiric treatment for Siphos present acute illness. (8) Discuss appropriate management of Siphos chronic lung disease. (10) Briefly discuss the ethical and legal issues related to the diagnosis of HIV in children. (6) Discuss co-treatment of tuberculosis and HIV in children. (6) [40]

Question 4 Mrs. Chauke lives in Malamulele in rural Limpopo. She is unemployed. Her husband is a migrant labourer in Johannesburg. She cares for four children including an infant and a female teenager. The two oldest children are her deceased sisters children. Three of the children receive a child social support grant. Her mother also lives with them in a two roomed home. Water is accessed from a communal tap and there is a pit latrine in the yard. Mrs. Friedman lives in Sandton (an affluent suburb in Johannesburg) in urban Gauteng. She is a bank manager. Her husband is a civil engineer. They have two children - a 3 year old and a teenager. They live in a 6 roomed house. The younger child attends a Montessori pre-school while the older is in a Model C school. Both parents admit to a stressful lifestyle. a) b) c) d) What do you understand by term social determinants of health? (2) Why are social determinants relevant to health? (1) Identify three social determinants that may negatively affect the health of the children residing in the Chauke family. (3) Describe the paediatric/child health relevance of one of these factors, i.e. explain how the determinant results in child ill health. (2)

e) f) g) h) i) j) k) l) m) n) o) p) q) r) s) t)

Identify two social determinants that may negatively affect the health of the children residing in the Friedman family. (2) Identify an example in the given scenario of a governmental action to address a social determinant of health. (1) What do you understand by the term health inequity? (2) Where are (i) the Chauke and (ii) the Friedman families most likely to seek healthcare related help? (4) Identify three inequities in the access to health care that children in the Limpopo-based family are likely to experience. (3) The immunisation uptake rate in the Friedman children may be lower than in the Chauke family. Offer two possible explanations for this. (2) For each family, briefly describe two possible environmental hazards that the children may be exposed to. (4) What is meant by a countrys burden of disease? (1) What is the usual metric (measurement) used to assess the burden of disease? (1) Suggest two disease burdens for which the teenager in the Chauke family is likely to be at higher risk than the teenager in the Friedman family. (2) Suggest two disease burdens for which the children in the Friedman family are likely to be at higher risk than the children in the Chauke family. (2) What is the under 5 mortality rate likely to be in Malamulele - the district where the Chauke family live? (1) What is under-5 mortality rate likely to be in the Sandton area? (1) What are the two most likely causes of death in under 5s living in the Sandton area? (2) What do you understand by the term cost-effectiveness of an intervention, and how is this usually expressed? (2) List two paediatric interventions that are likely to be highly cost-effective for both these families. (2) [40]