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 4 April 2013 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.

Write short notes on a) The causes, laboratory diagnosis and management of haemolytic uraemic syndrome. (10) b) The symptoms and signs of early as well as late congenital syphilis. (10) c) The causes and management of empyema. (10) d) The pathophysiology, presentation and diagnosis of Hirschprung disease. (10) [40] Write short notes on a) The advice you would give to parents regarding Malaria prophylaxis for South African children travelling to Malaria endemic areas. (10) b) Antibiotic stewardship in the ambulatory paediatric setting. (10) c) Assessment of a 7-year-old asthmatic child on inhaled corticosteroid treatment presenting for a six month follow up visit. (10) d) The clinical criteria for admission of an infant with bronchiolitis. (10) [40] a) Write short notes on the care dependency grant with regard to the following i) Requirements necessary to qualify for such a grant. (6) ii) The amount that is paid by such a grant. (1) iii) How long such a grant may be paid for? (3) b) Write short notes on predictors of outcome following near drowning. (10) c) Mrs M is the mother of a term, three-day-old male newborn who is about to be discharged from the post-natal wards and she requests your advice regarding circumcision. How will you advise her? (10) d) Jane is a 12-year-old girl who has been admitted with appendicitis and peritonitis and is scheduled for a laparotomy and appendectomy. (10) PTO/Page 2 Question 4

-2Write short notes on who may consent to this procedure according to current South African legislation. [40] 4 a) i) Define the following terms as used in a diagnostic test: Negative Predictive value (NVP) and Positive Predictive value(PPV). (5) ii) What factor(s) influence the predictive value of a clinical test? Discuss. (3) iii) Define the sensitivity of a diagnostic test. (2) b) i) Compare and contrast the two vaccines available against human papilloma virus infections (HPV). (5) ii) Write short notes on the recommended vaccination schedule for HPV.(Population and timing) (3) iii) Outline the possible barriers to introduction of HPV vaccination in the public sector services in South Africa. (Give at least four). (2) c) Discuss von Willebrand (VWD) disease under the following headings i) Types of VWD. (3) ii) Genetics and genetic counselling. (5) iii) Treatment options. (2) d) Vitamin A supplementation in children 6-59 months is an important public health intervention. i) Describe the current vitamin A supplementation programme (VAS) for children and womenin South Africa. (5) ii) Discuss the benefits of vitamin A supplementation in children. (5) [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 5 April 2013 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.

Joey is a 2-year-old child who has just been diagnosed as HIV infected. He weighs 10kg and has developmental delay. His mother is a 19-year-old schoolgirl. By day, Joey is cared for by his grandmother. Joeys mother was treated for TB when he was 6-months-old. The mother is not yet on antiretroviral therapy. a) i) What are the South African criteria for initiating antiretroviral therapy (ART) in children? ii) What are the South African ART treatment regimens? (10) b) What are the steps that you, as the doctor in charge, need to take before initiating ART in Joey? (10) c) How would you monitor treatment response in Joey? (10) d) What would you do if you suspect treatment failure in this child? (5) e) You are the paediatrician caring for this family. What management would you recommend for the mother? (5) [40]

A couple brings their 3-year-old daughter for a routine evaluation. The father is 45-years-old, the mother 40 and the child was born at the gestational age of 34 weeks. A family member (a speech therapist) is concerned about the fact that the child is only saying 20 words and does not combine them in two word sentences. a) What are your main differential diagnoses? (10) b) What are important pointers which will differentiate autistic spectrum disorders from a developmental language disorder? (5) c) Which screening tools and definitive gold standard tools are available to make the diagnosis of an autistic spectrum disorder? (5)

PTO/Page 2 Question 2 d)

-2-

d)

e) f) g) h) i)

The girl does fit the diagnosis of an autistic spectrum disorder. The parents are concerned about their 4-month-old son and do not want to immunise him because of the fear of that being the vaccination cause of autism. Discuss the newest information on the causes of autistic spectrum disorders with them. (5) Name 2 risk factors present in this couple for their daughter having an autistic spectrum disorder. (2) What is the risk of their son having features of autism? (2) What is their daughters risk of developing epilepsy over the next 20 years? (1) Discuss the principles of management of this girl. (8) The parents want to know about the evidence for a complementary intervention; What is your opinion on hyperbaric oxygen therapy for the treatment of autistic spectrum disorders? (2) [40]

John, an eight-year-old boy, presents to you with a one day history of severe headache and fever. He has vomited once. On examination he has signs of meningeal irritation, a decreased level of consciousness as well as a few petechiae on his conjunctivae. You suspect meningococcal meningitis.

a) b)
c) d) e) f)

Give a brief description of the causative organism. Describe the pathogenesis of the disease.
Which serogroups commonly cause disease in South Africa? During which time of the year do you expect to find an increase in cases in South Africa? Which laboratory investigations will you request and what results do you expect? Discuss your initial management of the patient.

(3) (3)
(2) (2) (6) (8)

Johns pregnant mother is concerned about herself and her younger daughter of 4-years-old and enquires about chemoprophylaxis.

g) h) i) j)

To whom should chemoprophylaxis be given? (5) For how long after index case identification will chemoprophylaxis still be beneficial? (2) Which drugs can be used for chemoprophylaxis for contacts in this case? (3) Should John receive antibiotics to eradicate meningococcal carriage? (1)

The infection control sister asks you whether contacts can be immunised to prevent disease.

k) l) m)

Discuss the use of immunisation to prevent disease in contacts. (2) Which different types of vaccines are available against meningococcal disease? (2) Against which common serogroup is a vaccine not commercially available? (1)
[40]

PTO/Page 3 Question 4

-34 Rejoyce is a 3-year-old girl who is referred to you by a local GP. The family have recently moved to your city from Kampala, Uganda, because her father works for an international mining corporation and has been transferred to South Africa. She has a 1-month-old brother, Caleb, who is well. She presents now with a 2 day history of pain in her left forearm. Her mom tells you that she has had a cold for a week and that this is not the first time she has seen a doctor for a similar problem. Her weight (15kg) and height (93cm) are appropriate for her age. She is febrile (T 385 C). Her urine dipstix is clear and her BP is 104/65 mm Hg. She has a sinus tachycardia of 125 bpm. She has normal perfusion and hydration. She cries when you examine her arm which is swollen and tender. She has a 4cm firm palpable splenomegaly. The rest of her clinical examination is unremarkable. The most likely diagnosis is Homozygous sickle cell anaemia (Hz-SCA). a) b) c) d) What initial screening and confirmatory tests will you perform to confirm the diagnosis? (2) What pitfalls may be associated with screening for this condition? (2) Describe the principles of management of such an episode. (6) After 3 days of treatment her fever has not settled and you discover that she is developing erythema in the soft tissue of the lateral forearm. What clinical complication are you concerned about? (1) What is the likely responsible organism? (1) Explain the pathophysiology of this complication. (2) List the common crises associated with this condition. (4) You admit the child for treatment. Investigations confirm your clinical suspicion. You give the parents the diagnosis. What advice will you give the parents about future pregnancies? (4) After you counsel them they express concern about their 1-month-old baby boy. They ask about screening for him. What important information must you elicit on history taking and what advice do you give them? (2) Why is Caleb asymptomatic? (1) If Caleb was found to have the same diagnosis as Rejoyce, what advice will you give the parents regarding immunisation? (5) List some of the five indications for blood transfusion in this condition. (5) What clinical and treatment related events would prompt you to seek advice and/or referral of this patient to a specialist paediatric haematologist? (5) [40]

e) f) g) h) i)

j) k) l) m)