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 20 August 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 1.1 Prophylaxis against Respiratory Syncytial Virus. 1.2 Prolonged QT interval in children. 1.3 Calculation, uses and interpretation of Z-scores in paediatrics. 1.4 Improvement of Infant Mortality Rates in South Africa.

(10) (10) (10) (10) [40]

2.1 You have been managing a 17-year-old adolescent with diabetes for the past 10 years. In the next 6 months, the adolescent is moving with her family to a new town where an adult physician will take over her care. Discuss the steps that you would take when planning her transition to adult care. (10) 2.2 a) Briefly define the following types of hearing loss i) Conductive hearing loss. ii) Sensorineural hearing loss. iii) Mixed hearing loss . iv) Central hearing loss. (4) b) How is profound hearing loss defined? (1) c) With the exception of genetic and syndromic disorders, list five factors that are associated with hearing loss in the neonate. (5)

2.3 You have just performed a routine examination on a healthy term male neonate born to a 17year-old adolescent mother. Whilst you perform your examination at the bedside, you notice that the mothers parents (i.e. the newborns grandparents) appear worried and anxious. Afterwards, the grandparents inform you that their daughter had previously delivered a female newborn baby when she was 15-years-old. Sadly, this female newborn was found dead in her bed when she was 7-days-old. Horrifyingly, the grandparents inform
PTO Page 2, Question 2.3....

you that they suspect that their daughter had deliberately suffocated her first child; they ask for your help to ensure that their newly born grandson does not meet a similar fate. a) Define the terms filicide, neonaticide and infanticide. (3) b) Briefly discuss the causative factors that may cause parents to kill their children. (7) 2.4 Abdominal ultrasound examinations are performed with increased frequency in children who are HIV-infected a) What are "splenic micro-abscesses"? (1) b) Name five diseases / disease-states that are associated with "splenic microabscesses". (5) c) Briefly discuss the clinical and therapeutic implications for a 2-year-old HIV-infected toddler noted to have "splenic micro-abscesses" on abdominal ultrasound. (4) [40] 3 3.1 Write short notes on the extra skeletal effects of Vitamin D. (10)

3.2 Write short notes on the following drugs including the mechanism of action, indications for use in children, side effects and known important drug-drug interactions a) Tenofovir. b) Clarithromycin. (10) 3.3 Write short notes on the National Department of Healths guidelines on INH prophylactic treatment in HIV infected and HIV uninfected children 0-14-years-old. (10) 3.4 A 3-year-old girl is investigated for recurrent episodes of fever. She has had 3 confirmed urinary tract infections in 6 months. Renal sonar reveals bilateral hydronephrosis and hydroureters. The voiding cystogram shows grade 3 vesico-ureteral reflux bilaterally. Discuss the further management of this child according to the most recent published guidelines on management of urinary tract infections. (10) [40] 4 4.1 Define hypoglycaemia in the neonate. Discuss the aetiology and outline the management of hypoglycaemia in the neonate. (10) 4.2 List the diagnostic criteria of Kawasaki syndrome. Briefly discuss the management. (10) 4.3 Write short notes on the ethical, legal and medical issues surrounding male infant circumcision. (10) 4.4 Write short notes on Viral Hepatitis A. (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 21 August 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. Question 1

You work in a tertiary level academic hospital. A 3-year-old girl, Sisipho, with known severe developmental delay, is referred by a local GP with a problem of cough for 3 days, high fever and increasing respiratory distress, requiring oxygen, despite antibiotic therapy. The mother has recently moved to town and stays in an informal settlement, a few kilometres from the hospital. She is a single unemployed mother of 4 children, and has another child with a disability that is looked after by the maternal grandmother in the rural areas. The other two siblings have moved with her to the new town. Sisipho was born at term by emergency caesarean section because the baby was tired, according to mom. She stayed in the nursery for two weeks postdelivery and was tube-fed for the first week. On examination Sisipho is noted to be underweight with a small head and no dysmorphic features. There is increased tone in all limbs with pyramidal tract signs and scissoring of the lower limbs. She has some head lag and cannot sit. In addition, she cannot speak or hear.
a) b) c) d) e) f) What is the most likely full diagnosis? (2) List the factors that are likely to contribute to the development of her respiratory problems. (4) What other medical problems is Sisipho likely to have or be at risk of? (6) Discuss your approach to the comprehensive evaluation of Sisipho (10) What is the prognosis for sitting and walking for Sisipho? Explain your answer. (4) How would you manage Sisipho, acutely and in the long-term? Include the ethical considerations in your management, with the history of this family in mind. (14) [40]

Question 2

The general practitioner refers Jannie, a twelve-year-old boy, to you. He has a serum cholesterol level of 6.7 mmol/l (normal < 5.2mmol/l). The cholesterol level was done since the father had recently died of a myocardial infarction. Jannie refuses medical treatment. a) Discuss the potential clinical findings and differential diagnosis. b) Discuss the most likely diagnosis and clinical management of Jannie. (10) (15)

c) Discuss the management of Jannies treatment refusal.

Question 3

(15)
[40]

Shuaib, a 12-month-old boy, presents to the casualty department with a 1 week history of fever, lethargy and poor feeding. He is tachypnoeic, lethargic, and has poor perfusion. His heart rate is 180/min, respiratory rate 60/min, and Blood pressure 70/40 mmHg. His oxygen saturation is 90 % on 2L nasal prong oxygen.
a) What is the diagnosis? Justify your answer. (4)

An arterial blood gas (ABG) is done, and shows the following: pH: 7.00 pCO2: 2.5 kPA pO2: 6kPA, HCO3:10 mmol/l BE 15 mmol/l, SaO2: 88% Lactate 8 mmol/l b) c) d) Interpret the ABG. (2) List FOUR other metabolic complications that you will look for in this patient. (4) Discuss the principles of fluid resuscitation of the patient. Comment on the use of crystalloids versus colloids in this resuscitation. (10)

Intravenous access is difficult and you elect to insert an intra-venous femoral line. e) f) g) Indicate the landmarks for the intravenous femoral line insertion. (4) Indicate the consequence/s associated with injuring the 2 vital structures next to the femoral vein. (4) List the THREE main vasoconstrictors used in the management of shock, and for each of these list THREE side effects. (12) [40]

Question 4

Six-year-old Amanda presents to the local clinic with pallor, a productive cough, and poor weight gain. She has had several episodes of dyspnoea in the past year. At the clinic she is assessed to have anaemia and is classified as not growing well.
a) How is anaemia classified according to the IMCI guidelines? (2)

An assessment is made that iron deficiency is the likely cause. The child is treated for worms and is started on a trial of iron therapy. b) c) d) List the non-haematological effects of iron deficiency. (5) In the Paediatric Essential Drugs List, a diagnostic criterion for iron deficiency is response to a trial of iron therapy. How is this done and what is the total duration of treatment? (3) What preparations of iron are available at clinic level and how much elemental iron is present?(3)

At follow up Amanda is noted to have an inadequate response to iron and she is referred for further investigations. She is still coughing and there has been some weight gain. The caregiver says there is good compliance. The following results were obtained. Full blood count: Hb 6.0g/dl (10.7-14.7); MCV 66 fl (75-87); MCH 20 Picogram (24 -30); MCHC 28g/dl (31 37); RDW 23% (11 15); Reticulocyte count corrected 1.5% Platelets: 480 x 109/l (180 -440); WCC: 8 x 109/l (6 - 16); Differential: Neutrophils 50% Lymphocytes 50% Serum Iron: 4 mol/L (9 21); Serum Transferrin: 4.4 g/l (2.02 3.5); Transferrin Saturation: 11%; Ferritin: 80ug/L (36 92) Stool microscopy: no parasites, no RBCs; Urine: normal

5 CXR patchy bilateral interstitial shadowing Sputum Culture and GeneXpert for TB negative x 3 e) f) g) h) i) j) Interpret the full blood count. (2) How is the corrected reticulocyte count done and why is this done? (2) What is the RDW and how does the RDW assist in your assessment of this patient? (2) Interpret the iron studies in this patient. (2) Give reasons for the poor response to iron treatment. (4) What features in the above results support iron deficiency anaemia rather than anaemia of chronic disease? (2) k) What further investigations would you do on the sputum of this child and why? (4) l) Give 3 indications for the use of parenteral iron therapy. (3) m) Briefly explain the role of the following in iron metabolism i) Ferroportin. (2) ii) Divalent metal transporter 1 (DMT 1). (2) iii) Hepcidin. (2) 40]