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 March 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.

Write short notes on the a) The indications for and an approach to investigating primary immune deficiency. (10) b) Supportive care of a patient receiving peritoneal dialysis for chronic renal failure. (10) c) Analgesia in the neonate. (10) d) The diagnosis and management of Familial Hypercholesterolaemia. (10) [40] Write short notes on a) Indications for and side effects of Propranolol in Paediatrics. (10) b) Discuss the diagnosis and causes of virological failure in children on antiretroviral treatment. (10) c) Corporal punishment of children from a Paediatricians viewpoint. (10) d) Diagnosis and treatment of functional constipation. (10) [40] Write short notes on a) Clinical features and treatment of acute disseminated encephalomyelitis (ADEM). (10) b) Clinical features and types of epidermolysis bullosa. (10) c) The clinical features and management of a neonate with congenital ichthyosis (collodion baby). (10) d) The diagnosis, management and complications of inhibitor development in a patient with Haemophilia A. (10) [40] PTO/ Page 2 Question 4

-24 Write short notes on a) Signs and symptoms of early sepsis in the neonate. (10) b) Discuss the inflammatory markers that a Paediatrician in practice would commonly use. (10) c) Discuss factors that would assist you to determine the risk for developing asthma in a preschool child with recurrent wheeze. (10) d) Complications of measles. (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 22 March 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 A 6-year-old boy presents to you with peri-orbital and pedal oedema. a) b) What is the differential diagnosis of oedema in this age group? (10) What initial side-room and laboratory investigations would you perform? Motivate your answer. (5)

His mother tells you that he has had intermittent diarrhoea for the preceding 6 months. On examination his weight is below the third centile and his height is on the fifth centile. He has pitting oedema of the legs and some peri-orbital oedema. Further examination is unremarkable. Special investigations Total protein 33g/l (normal 60-80); Albumin 15g/l (normal 32-50) Total calcium 1,4mmol/l (normal 2.1-2.5) Magnesium 0,56mmol/l (normal 0.74-0.96) Full Blood Count Haemoglobin 9,4g/dl; Platelet 158 x109/l. White cell count 8x109/l [abs. Neutrophil count 6 x109/l; abs. Lymphocyte count 0,9 x109/l]; HIV ELISA: negative c) d) e) f) Comment on the results of the special investigations. Given the additional information, what diagnoses would you consider and why? How would you proceed to confirm the diagnosis? Discuss your management of the patient. (5) (5) (5) (10) [40]

PTO/Page 2 Question 2

-2-

Question 2 A well educated mother of a 2-year-old is concerned because he has lost some words and he has developed some unusual mannerisms. She is worried about autism in her child. She links this to the measles vaccine given to him and wants to sue the Paediatrician who encouraged her to vaccinate her son. How are you going to explain the following to her? a) b) c) d) e) f) g) h) What is autism? What causes autism? What is the prevalence and is there any difference between boys and girls? What is the risk to have another child with autism? What characteristics may be indicative of autism in a 2-year-old child? What is the current evidence based opinion about immunisation and autism? The tools that may be helpful in the screening and diagnosis of autism. Pharmacological treatment options. (5) (5) (3) (5) (10) (2) (5) (5) [40]

Question 3 Housing policy and planning have direct relevance for childrens health and wellbeing. The United Nations Conventions on Rights of the Child recognises the right of every child to a standard of living adequate for the childs physical, mental, spiritual, moral and social development. Accordingly South Africas response to MDG 7 addresses this through the national housing plan, which aims to eliminate all informal housing in the country by 2020. The issue of safety for children requires further attention. a) Accidental ingestion of harmful substances may be fatal among children. Describe i) Public health measures to prevent this form of injury. (14) ii) Health-system measures to prevent deaths subsequent to injury. (4) List 3 types of unintentional injuries (apart from the above) that children living in informal settlements in South Africa are especially vulnerable to. (6) Intentional or forced ingestion of harmful substances, or medication overdose, may occur in the setting of child abuse in a young child or deliberate ingestion in an older child. What are the features that should raise suspicion of such occurrences? (6) Describe the principles of management of a child with suspected poisoning in the clinical setting. (10) [40]

b) c)

d)

Question 4.1 A 14-year-old single mother, staying with her parents, gave birth to a male infant weighing 3.2kg, with a head circumference of 40 cm and length of 52 cm. On neurological examination, the infant was noted to have minimal movement of the lower limbs with hypotonia and depressed deep tendon reflexes (knee and ankle) ; the upper limbs had normal movement, tone and deep tendon reflexes. The Moro reflex was noted to be incomplete and the baby had good grasp but poor suck. a) When are the following primitive reflexes fully developed and when do they disappear during the normal development of an infant? i) Grasp reflex. (2) ii) Moro reflex. (2) iii) Asymmetric tonic neck reflex. (2) What other aspect of the central nervous system would you examine in this patient?(2) What is the most likely diagnosis? (1) Which factors are implicated in the development of this condition? (3) PTO/Page 3 Question 4.1 e)

b) c) d)

-3e) The doctors approached the mother to give consent to include the infant in a research study. Can the mother give consent for the infant to be included in the study? Give reasons to support your answer. (2) The infant developed signs of intestinal obstruction and laparotomy was indicated. The doctors approached the mother for consent. Can the mother give consent? Give reasons to support your answer. (2) The patient is discharged home after three weeks of hospital stay, and he comes back 5 days post-discharge with fever and irritability and is diagnosed with urinary tract infection (UTI). i) How does one make a diagnosis of UTI? (2) ii) How would you manage this patient? (4) iii) What is the most likely predisposing factor for his UTI? (1) [23]

f)

g)

Question 4.2 Before you discharge the baby you plan to start the patient on antibiotic prophylaxis, but one of your colleagues makes you aware about an article that was published a week ago with the following results: The study recruited children from birth to 18 years who had at least one episode of UTI. Six hospitals recruited patients. Children with a known skeletal or neurologic abnormality were excluded. All children were followed every three months for a year. The primary outcome was symptomatic UTI within 12 months. The investigators planned to enrol 780 patients (390 patients in a placebo group and 390 in a study drug group) in order to provide the study with a power of 80%, and with a type I error of 5%. The results of the study are summarised in the table below

Number with any UTI Number with UTI with fever Number with UTI requiring hospitalisation a) b) c) d)

Study drug (n=288) 36 19 23

Placebo (n=288) 55 36 29

Statistics Hazard ratio in antibiotic group was 0.61, 95% Confidence Interval was (0.40-0.93) Risk difference was 6 95% Confidence Interval (1-11) Risk difference was 2 95% Confidence Interval (-3 - 7)

e)

What study design was used in this trial? (2) What does type I error mean? (2) What are the percentages of patients with any UTI in the study group and Placebo group? (4) Were there statistically significant differences between study group and Placebo group in the following? Motivate your answers i) Any UTI. (1) ii) UTI with fever. (1) iii) UTI requiring hospitalisation. (1) Would you use the results of this study in marking decision to use prophylaxis in your patient? Give reasons for your answer. (2)

PTO/Page 4 Question 4.2 f)

-4f) g) Do the results of this study assist you in your decision to start this patient on prophylaxis before discharge? Give reasons for your answer. (2) How do you calculate risk difference? (2) [17]