DCH Paper I  31 March 2005

 

1          a)         Briefly describe hearing tests recommended to screen for hearing loss in young babies. What questions would you ask the caregiver (parent) of a 9-month-old baby if you were screening for hearing loss?

 

b)                 Describe briefly the clinical features and management of giardiasis in children?

 

c)                 How would you manage a child who presents with paraffin ingestion?

 

d)                 Describe common clinical complications seen in a child who has spastic quadriplegia?

 

 

a. The hearing test recommended to screen for hearing loss in newborn babies is called the Otoacoustic emissions (OAE’s) – otoacoustic emissions (cochlear echo) are the sounds a normal cochlea produces in response to receiving an external sound. The absence of an echo can indicate a loss of hearing.  It is non-invasive, does not require co-operation and can be used to screen newborn babies with a family history of hearing loss or those exposed to factors that may predispose them to hearing loss or deafness (Jeffrey 1995). Distraction tests are still done in infants from the age of 6 – months but have not been found to be reliable.

 

It is commonly recommended that screening be done by asking the parent or caregiver questions which will identify the baby at risk or will lead to suspicions that the infant has a hearing loss. An audiologist should formally assess such infants.

Recommended questions to the caregiver (parent) of a 9 month old baby if you were screening for hearing loss are:

 

·         Is there a family history of deafness?

·         Was the infant born prematurely?

·         Did the infant require ventilation for 5 days or longer?

·         Did the infant have a low Apgar score? (0-4 at 1 minutes or 0-6 at 5 minutes)

·         Was the infant significantly jaundiced?

·         Is there a history of intra - uterine infections?

·         Does the infant have craniofacial abnormalities?

·         Was the infant admitted to ICU?

·         Has the infant been treated with amino glycosides?

·         Has the infant had bacterial meningitis?

·         Does the infant vocalize?

·         Does the infant respond to sounds?

 

  1. Describe briefly the clinical features and management of Giardiasis in children?                                                                                                        (5)

 

Giardiasis is transmitted via contaminated water or direct contact. Prevention of the infection is therefore through ensuring a clean water supply and the washing of hands before eating or the preparation of food.

 

Acute giardiasis may present with explosive watery diarrhoea, abdominal discomfort, distension, nausea and anorexia. The condition can resolve with or without the patient developing into a carrier. Some children develop low-grade chronic or recurrent diarrhoea with weight loss and debility. The stools are pale, bulky, and offensive and float in the toilet due to the high fat content as is typical of a malabsorbtion syndrome.

 The condition is usually treated with Flagyl (Metranidazole) 25-50 mg Kg per day in three divided doses for 5 days.

 

c. How would you manage a child who presents with paraffin poisoning?          (5)

 

The main most common problem with Paraffin poisoning is the volatiles, which are released from the paraffin and cause a chemical pneumonitis resulting in hypoxia. The pneumonitis may not be present immediately and children should be admitted for at least 6 hours for observation. Oxygen therapy is essential in the child that is symptomatic.

Fluids should be limited to twice the insensible loss as over hydration will result in pulmonary oedema.

Pyrexia is a common finding and does not indicate a bacterial infection. Paracetamol can be used to control the pyrexia. Antibiotics are not always necessary.

Emetics are absolutely contra indicated.

 

d. Describe the common clinical complications seen in a child with spastic quadriplegia?                                                                                                 (5)

 

Spastic quadriplegia is a form of cerebral palsy, which is usually associated with severe brain damage involving the cortex.  The common associated findings are therefore cognitive impairment seen as mental retardation, which is usually moderate or severe. These children are also usually microcephalic. They commonly have epilepsy.

The damage to the motor cortex of the brain causes an imbalance between the flexor and the extensor muscles with increased flexor tone. This results in the development of contractures across the joints.

Although there is increases tone in the limbs these children frequently have poor head and trunk control resulting in poor posture and a secondary scoliosis.

The lack of movement and secondary deformities predispose these children to pneumonia, constipation and bedsores.

The muscles of mastication and swallowing are frequently involved resulting in feeding difficulties and failure to thrive. They are also at risk for aspiration due to poor swallowing or gastro oesophageal reflux. Poor swallowing and prolonged bottle feeding puts these children at an increased risk for dental caries.

These children frequently have language delays which may be very severe not only because of the poor control of the muscles required for speech but also due to the cognitive problems. There is also a higher incidence of deafness in these children.

Because of the diffuse nature of the brain damage the occipital cortex and /or the optic nerves may be involved resulting in various degrees of visual impairment.

 

 

 

2          a)         Discuss the practical and prognostic advantages and disadvantages of the Wellcome classification of nutritional state.

b)                 Discuss the main causes for, and interventions to reduce infant mortality.

c)                 Discuss how to counsel a mother wanting to stop breastfeeding her 3-month-old child because of insufficient breast milk.

d)                 Describe the three main components of the Integrated Management of Childhood Illness strategy.

       a) Simple in that only requires measurement of weight and presence / absence of oedema. Therefore has scope for use by wide range of health staff with varying skills.

                     i.             But only relates to identification of severe malnutrition i.e. does not pick up on more subtle signs of malnutrition

                   ii.             Highlights marasmus (<60%EWA) as an entity and not just kwash as a sign of severe malnutrition (though kwash is more dramatic)

                  iii.             Oedema is used as a surrogate for other signs of severe malnutrition e.g. dermatosis

                 iv.             The presence or absence of oedema is regarded as a key differentiating sign with prognostic implications

                   v.             Relates findings to age

                 vi.             Does not take into account length/height

                vii.             This has the advantage of avoiding the difficulty of accurate length/height measurements but limits the interpretation

              viii.             Classification is limited because weight will be influenced by presence of oedema

                  ix.             Can be adjusted for by using minimum weight after loss of oedema

                    x.             Cannot distinguish between acute and chronic malnutrition

                  xi.             Allows comparison of types of severe malnutrition in different places e.g. clinic vs. hospital or by country or to examine social or environmental differences between marasmus and kwash

 

b)

                     i.             Over 10m children die per year

                   ii.             Most occur in sub-Saharan Africa (~40%) and South Asia (34%)

                  iii.             Cause of deaths are often the result of more than one process e.g. measles followed by pneumonia or diarrhea; HIV and pneumonia or diarrhea.

                 iv.             Cause should be classified as combination as demonstrating co-mobidities has important public health implications

                   v.             Neonatal disorders still accounts for 20-40% of all infant deaths

                 vi.             Factors placing infants at increase risk of death include

·         Unhygienic conditions

·         Unsafe conditions

·         Poor birth spacing

·         Non-breastfeeding

·         Non exclusive breastfeeding

                vii.             Underlying causes of death

·       Measles

·       Underweight

·       AIDS (accounts for

·       Vitamin A deficiency

·       Prematurity

              viii.             Main clinical causes of death in sub-Saharan Africa

·       Malaria (~22%)

·       Diarrhoea (~20%)

·       Pneumonia (~21%)

·       Neonatal disorders (~25%)

·       AIDS (~8%) – this might be as high as 30% in South Africa

                  ix.             Interventions can be divided into Preventive and Treatment

                    x.             Preventive interventions with established evidence-base would include:

·         Breastfeeding

·         Insecticide-treated materials e.g. bednets

·         Good complementary feeding practices

·         Good water supply

·         Immunisations

·         Zinc supplements

·         Vitamin A supplements

                  xi.             Treatment interventions with established evidence-base would include:

·         Oral rehydration therapy

·         Antimalarials

·         Appropriate and timely antibiotics for pneumonia, sepsis, dysentery

·         Zinc and vitamin A supplementations

·         Neonatal resuscitation including management of hypoglycaemia, hypothermia, asphyxia

                 xii.             The Integrated Management of Childhood Illness strategy is founded on these principles

 

c) 

                     i.             Listen to mother i.e. counsel vs. advise

                   ii.             Explore if there are other reasons for her saying that she intends to stop breastfeeding e.g. returning to school, tired of breastfeeding

                  iii.             Evaluate feeding practices so far – technique (attachment and positioning), difficulties encountered, family expectations, number of wet nappies per day as indication of adequate intake

                 iv.             Check Road to Health Card for child’s weight

                   v.             Check knowledge of physiology of breastfeeding i.e. more suckling = more milk

                 vi.             Discuss the benefits of continued breastfeeding especially exclusive breastfeeding

                vii.             Explain about growth spurts and increase requirements

              viii.             Explain about non-nutritive suckling

                  ix.             Explore HIV status of mother and child

                    x.             Discuss early +- rapid cessation of breastfeeding if relevant (HIV-infected mother and uninfected child)

                  xi.             Guide mother to optimal breastfeeding technique if she decides to revert to BF

                 xii.             Ensure that she understands about hygienic and adequate preparation of formula feeds if she chooses to introduce formula

               xiii.             Identify ways in which family can better support

 

d)  

IMCI supercedes previous WHO programmes e.g. CDD or ARI.

 

Consists of three components i.e.

A. Standard treatment guidelines (STGs)

                     i.             Aims to reduce the rate of 5 main causes of childhood mortality globally – ARI, Diarrhoea, Measles, Malaria, Malnutrition

                   ii.             In South Africa, HIV (+common ear problems) also added

                  iii.             STGs underwent a local adaptation process both nationally and provincially

                 iv.             First step is a triage process i.e. looking for General Danger Signs

                   v.             Common approach – Ask, Check, Classify

                 vi.             Treatment based on classification rather than diagnoses

                vii.             Colour-coded algorithms

              viii.             Includes guidance on follow-up + counseling for prevention

                  ix.             Generally needs 60% staff in any given facility to be trained in order for it to become routine practice

                    x.             Training followed by supervision on site

 

B. Household and Community Component

                     i.             Aims to establish 15 key family practices

                   ii.             These cover issues such as breastfeeding, immunizations, disease prevention, early and appropriate treatment of common conditions e.g. use of ORS, improved health-care seeking practices

                  iii.             Also aims to improve the relationship and communication between primary health care facilities and local community

                 iv.             No single approach but includes identifying local resources and potential community partners

                   v.             Multisectoral approach – should include participation of other non-health sectors e.g. water and sanitation, social welfare, transport – to increase feasibility of achieving key family practices

 

C. Health Systems Review

                     i.             Aims to improve the infrastructure of health systems so as to enable primary care practitioners to effectively conduct their work

                   ii.             Includes national, provincial and local activities

                  iii.             Links with Essential Drugs List re. availability and dispensing of drugs

3          a)         Discuss the initial management of a newborn born to a mother with meconium stained liquor.

 

b)                 Describe the management of hypercyanotic spells in a child with Fallot’s tetralogy.

 

c)                 Describe briefly the acute and chronic complications of otitis media.

 

d)                 List valid contraindications to administering the routine expanded programme of immunisation (EPI) vaccines.

 

a) Passage of meconium in utero can occur as a result of fetal stress caused by hypoxia & acidosis.

 Meconium effects --- toxic to lungs causing mechanical obstruction, chemical pneumonitis, pulmonary vasoconstriction and inactivation of surfactant.

 

Thin or thick meconium can lead to MAS in new born

Intrauterine aspiration : 1) Vigorous baby—routine care = keep warm, suction mouth + nasopharynx, stimulation, ± oxygen

2) Depressed baby---keep warm, free flow oxygen, no stimulation, direct laryngoscopy & suctioning of mouth & hypopharynx followed by intubation and direct suction through the ET tube as tube is withdrawn. Repeat procedure until little meconiun is recovered.

Nasogastric tube can be inserted through ET tube for suctioning while giving IPPV.

Transfer baby to neonatal ICU or high care.

Intravenous fluids & antibiotics--- gram + & gram – cover.

Severe distress—ventilation and surfactant can be given.

 

b)

A) Precipitating factors—iron defiency anaemia, pneumonia, dehydration, excessive crying, hot baths.

 

B) Acute management

2) Administer 100% oxygen , ↑ blood flow to R side of heart → bend legs at the hips and knees ( squatting) and give fluids 20ml/ kg Ringers lactate or normal saline. Ensure adequate hydration.

3) Monitor saturation, heart & respiratory rates and acid – base status if possible.

4) Sodium bicarbonate IVI 8.5% diluted to 4.2% -- 2ml/ kg or use formula to calculate amount needed if  blood gas can be done.

5) Propanolol—IV 0.1mg/kg over 3 minutes or oral prapanolol followed by maintenance dose of propanolol 1-5mg/kg in 3 doses

6) Morphine if poor response to above—0.1-0.2 mg/ kg    .

 

C) Prophylaxis

  1) Iron treatment to all infants with cyanotic heart disease

  2) Propanolol 1-3mg/kg

 

 

c)    The complications can be in the ear, intra-temporal or intracranial.

1) Hearing loss—common. Acute hearing loss caused by ear effusions, ↑ tension and stiffness of the round window membrane—usually reversible.

Chronic hearing loss due to adhesive otitis, tympanosclerosis or ossicular discontinuity.

2) Perforation—rupture of the eardrum --- chronic suppurative otitis media with mastoiditis.

3) Aquired cholesteatoma—saclike structure formed by desquamating epithelial cells . Causes foul smelling discharge. Can invade and destroy other structure of the temporal bone. Intracranial spread can also occur.

4.) Mastoiditis—inflamed mastoid cells. Causes peri-auricular swelling & tenderness.

  Pinna is displaced inferiorly and anterioly.

5) Tympanosclerosis—deposits on tympanic membrane causing hearing loss.

6) Facial nerve paralysis—exposure of facial in the bony canal.

7) Suppurative labyrinthitis—direct invasion of bacteria to the inner ear canal. Signs—vertigo, nystagmus, tinnitus, hearing loss, nausea and vomiting.

8) Ossicular discontinuity—disruption of ear ossicles

9) Petrositis—temporal bone infection.

10) Intracranial complication—meningitis, focal encephalitis, brain abscess, sinus thrombophlebitis, extradural & intradural abscess.

 

 

d)

1) Inactivated vaccines absolute contraindications

Ř       Severe febrile illness

Ř       Severe inter –current infection

Ř       Allergy to egg protein— vaccines grown in egg yolk

Ř        Pertussis vaccine--Fits and unstable brain damage, progressive brain disease, previous  severe reaction—shock, collapse, screaming for hours post vaccination, convulsions and encephalopathy.

 

2) Live attenuated virus vaccines   .

Ř       Pregnancy

Ř       Allergy to egg protein

Ř       Children with malignant disease on high dose cytotoxic drigs, irradiation

Ř       Large doses of steroids or other immunosuppressive treatments—post organ transplant

Ř       Within 3 weeks of another live vaccine

Ř       Within 3 weeks or 3 months of a dose of normal immunoglobulin

Ř       BCG—NOT to be given to symptomatic AIDS children or a child with a positive tuberculin skin test, generalized skin conditions like extensive eczema—give only in  a site with normal skin.   

 

 

4          a)         Describe night terrors and how you would manage them.

b)                 Describe your management of a 5-year-old child with the recent onset of faecal soiling.

c)                 Discuss pain management during investigations involving skin puncture in children.

d)                 Write short notes on the formulations of oral rehydration fluid in diarrhoeal disease in children. What advice would you give to the mother of a child with diarrhoeal disease on the use of oral rehydration fluid?

 

a)       Describe night terrors and how you would manage them

 

Night terrors occur most commonly in children aged 5 and 7 yrs, and more commonly in boys.  The child suddenly wakes up screaming and appears very frightened, but says little or nothing. He cannot be consoled, and is unaware of his parents or surroundings. Within a few minutes the child settles and goes back to sleep, with no memory of the episode the next morning. Parents should be re-assured that night terrors are a fairly common occurrence in children, and usually short-lived. In children with persistent and prolonged night terrors, an underlying emotional disorder should be considered, and a short course of diazepam or imipramine may be considered while the family dynamics are being explored.

 

 

 

b)       Describe your management of a five-year old child with the recent onset of faecal soiling.

 

Faecal soiling, the involuntary passage of faeces into the clothing or bedclothes, must be distinguished from the voluntary passage of faeces in places that are inappropriate for the social and cultural background of the child.

 

For faecal soiling, exclude neurologic deficits on examination. In their absence, faecal loading, with consequent stool liquefaction and “overflow” incontinence is most likely. The diagnosis may be confirmed by palpating hard faeces in the abdomen or on rectal examination, although an abdominal x-ray may be necessary to confirm the loading of the colon with faeces.

 

The faecal loading should be cleared. Fleet or Microlax enemas for three days may be effective,

but large volumes of a balanced electrolyte polyethylene glycol solution (given orally) may be

necessary. After clearance, daily complete evacuation of the bowel must be re-established. This

will take several months. Careful explanation of the objectives of treatment is necessary, and both

child and parents should be involved in the management. Follow-up and support is essential.

 Encourage regular daily bowel habits and a fibre-rich diet. A laxative is usually necessary for

several months, starting with a bulk laxative, although a stool softener (e.g. lactulose) or a

 stimulant (e.g. senna) may be necessary.

 

 

c)       Discuss pain management during investigations involving skin puncture in children.

 

Children, including newborns, feel and remember pain. Anxiety aggravates pain. Prevent pain when predictable, and always allay anxiety. Discuss the planned procedure with the child (if appropriate) and parents. Help the parents to allay the child’s anxiety.

 

The management of the pain depends on the individual child, the type of procedure, how long and how painful the procedure will be, how still the child needs to lie and the child’s airway and physical status. For skin puncture use topical local anaesthetic, if available, allowing sufficient time before the procedure for the medication to work. In young infants, non-nutritive sucking, sucrose solution and breastfeeding are helpful. For more invasive investigations, such as lumbar puncture, topical application of local anaesthetic, if available, and skin infiltration may be necessary. If the child is anxious, an anxiolytic such as hydroxyzine, midazolam or other benzodiazapine may be needed.

If systemic analgesics are used, a combination of analgesics, such as paracetamol, codeine and a non-steroidal anti-inflammatory optimises analgesia and minimises the side-effects of any one drug. 

 

d)       Write short notes on the formulations of oral rehydration solutions in diarrhoeal disease in children. What advice would you give to the mother of a child with diarrhoeal disease on the use of oral rehydration fluid?

 

Oral rehydration solutions may either be mixed at home using sugar and salt, or reconstituted from specially prepared sachets.

 

The oral rehydration solution (ORS), mixed from sachets in a litre of water, contain sodium,

glucose (2%), potassium (20mmol/l) and base (30mmol/l). The World Health Organization

 previously recommended a sodium content of 90mmol/l, but a sodium content of approximately

60mmol/l, similar to the concentration used in South Africa, and in half-strength Darrows solution,

 is preferable in areas without a high prevalence of cholera.

The use of home mixed salt and sugar solution (SSS) is probably a more sustainable strategy than sachets, and promotes a greater degree of self-reliance in caregivers. It is particularly useful in preventing dehydration. However mixing may be less accurate, and home-mixed solutions do not contain potassium or base. The usual recommendation in South Africa is to use 8 level teaspoons of sugar plus half a level teaspoon of salt added to a litre of water.

 

Teach the mother how to mix and give the oral rehydration solution. Give frequent small sips from a cup, or cup and spoon. Give as much as the child wants, offering 15-30ml/kg/hour. If the child vomits, wait 10 minutes, then continue, but more slowly. Continue giving extra fluid until the diarrhoea stops.

 

 

5          a)         A 6-month-old, previously healthy boy, presents with respiratory distress. His mother has been suffering from a cold for a week. On examination his temperature is 38oC. Hyperinflation and wheezing are the most prominent clinical findings. Laboratory investigations show a normal white blood cell count and a normal CRP.

           

i)                    What is the most likely diagnosis?

ii)                  Which organism(s) is/are the most likely cause of his illness?

iii)                Briefly describe your treatment of this patient.

 

b)                 A neonate presents to you within 24-hours after birth with a swelling on his head. Tabulate the possible causes for the swelling and the distinguishing features for each cause.

 

c)                 Briefly describe the diagnosis, prevention and complications of hepatitis A virus infection in children.

 

d)                 Discuss the indications for passive immunisation in children.

 

a.         

·         What is the most likely diagnosis?

§         Acute viral bronchiolitis

§         Acute viral bronchopneumonia (mixed picture)

·         Which organism(s) is/are the most likely cause of his illness?

§         RSV

§         Adenovirus

§         Parainfluenza virus

§         Influenza virus

·         Briefly describe your treatment of this case.

§         Oxygen to prevent hypoxia

§         Fluids per mouth or NG tube, IV restricted to 60ml/kg

§         Trial of adrenaline or

§         Trial of Beta 2 agonists or Ipratropium bromide

§         Steroids generally not helpful

§         Antibiotics not indicated unless:

·         WBC > 15.0 x 109/l

·         Temp > 38,5oC

·         Patchy opacification on CXR

§         Ventilatory support if necessary

 

b.        A neonate presents to you within 24 hours after birth with a swelling on his head. Tabulate the possible causes for the swelling and the distinguishing features for each cause.

 

 

 

Sub-aponeurotic haemorrhage

 

 

Diffuse, underneath aponeurosis, sometimes after vacuum or forceps delivery, may be present at birth, increases during first 48 hours, crosses suture lines, bluish discoloration of upper eyelids, severe anaemia, shock, jaundice, treated with vitamin K or urgent blood transfusion

 

 

Sub periosteal haemorrhage/ cephalhaematoma

 

Localized, usually parietal, under periosteum, presentation sometimes only after 4-6 hours, larger over next 48hours, persist 6 – 8 weeks, centre may fluctuate, anaemia, jaundice, rarely underlying fracture, observation only

 

Caput succedaneum

 

Diffuse over presenting part, present at birth, petechiae over swelling, disappears within 48 hours, no complications or treatment

 

Vacuum extraction haematoma

 

Localized swelling of skin and subcutaneous tissue, present at birth, localized abrasions at periphery of swelling, skin may be purple, subsides in 5 – 7 days, may become infected, treat complications

Encephalocoele/meningocoele

Midline fluctuating, may be open with brain tissue protruding

 

 

c.        Briefly describe the diagnosis, prevention and complications of hepatitis A virus infection in children.

 

Diagnosis

                                                         i.      Contact history

                                                       ii.      Clinical picture

§         Usually mild

§         Often anicteric or asymptomatic

§         Prodromal symptoms

·         Nausea, vomiting, diarrhoea, fever, malaise, abdominal pain

§         Jaundice

§         Tender hepatomegaly

§         Urine dark, stools pale

§         Resolves within 2 week- 4 weeks

 

                                                      iii.      Serology

                                                                                       i.       IgM antibody to HAV

                                                                                     ii.      Increased transaminases

 

Prevention

                                                               i.      Adquate sanitation

                                                             ii.      Safe drinking water

                                                            iii.      Good personal hygiene

                                                            iv.      Isolation (not to school)

                                                             v.      Nomal immunoglobulin/Vaccine for post exposure prophylaxis

                                                            vi.      Vaccine

 

 

Complications

     

                                                               i.      Fulminating hepatitis

                                                             ii.      Aplastic anaemia (very rare)

 

d.        Discuss the indications for passive immunisation in children.

 

·         Hepatitis A, Household or day-care centre contacts given immunoglobulin within 2 weeks of exposure

·         Rabies, Rabies immunoglobulin post exposure

·         Hepatitis B, HBIG given o newborns of mothers with acute or chronic hepatitis within 12 hours of delivery

·         Varicella, VZIG within 96 hours for susceptible children, newborns of moms who contracted chickenpox between 5 days before to 2 days after delivery

·         Measles, Exposed susceptible children, Immunoglobulin within 6 days of exposure

·         Tetanus, TIG For treatment in newborns and older children, Prophylactically in severe wounds in incompletely immunized children

 

 

 

 

DCH Paper II  March 2005

 

1          A 10-year-old boy presents to your hospital with petechiae, headache and a fever that started a few hours before he came to the hospital. He mentions that one of his classmates was admitted to hospital in the previous week with meningitis.

 

a)         Which organism is most likely to be responsible for his illness?                                                                                                                      (2)

b)                 Discuss the clinical features of infection with this organism.                                                                                                         (10)

c)                 Motivate special investigations that you will do in his case.                                                                                                                         (6)

d)                 Describe your treatment of this patient.                                                                                                                                                            (12)

e)                 Discuss primary and secondary prevention of this disease.                                                                                                                      (10)

 

 

a.                   Which organism is most likely to be responsible for his illness?                        (2)

N. meningitidis

 

b.                   Discuss the clinical features of infection with this organism.                             (10)

Incubation period of 2 – 4 days

35% Meningitis

15% Septicaemia

50% Both

Fever,chills and prostration.

May be hypothermic

Rash typically petechial or purperic, evolves rapidly, involves mucosa

Occasionally maculo-papular rash

Irritability, lethargy

Signs of meningitis

Menigeal irritation

Positive Kernig and Brudzinski

Headache, vomiting, , stupor, coma

Extensive purpura, DIC, Shock

Seizures, not as common as in pneumococcus or H. influenzae

Other: Pneumonia, myocarditis, pericarditis, septic arthritis (rare)

Case fatality 8 – 25%

 

Poor predictive factors

      Rapid onset

Shock

Coma

Acidosis

Seizures

DIC

Absence of meningitis

 

Adrenal haemorrhage (Waterhouse Friderichsen syndrome

 

Chronic meningococcemia

 

c.                   Motivate special investigations that you will do in his case.                               (6)

Blood culture

FBC with differential count

Acute phase reactants

LP not done when fears of raise intracranial pressure/ some authors - never in suspected N.meningitides meningitis

Lumbar puncture

      Microscopy

Culture

      Biochemistry

      Cell count

Capsular antibodies in CSF or urine

Skin scrapings for microscopy and culture or biopsy

Buffy coat microscopy

Electrolytes if adrenal haemorrhage or SIADH

 

d.                   Describe your treatment of this case.                                                                (12)

 

Diagnostic workup

Emergency

First dose of antibiotics

Parental Penicillin or third generation cephalosporin,

Penicillin resistant strains described

Chloramphenicol for Beta-lactam allergic patients

Continue 5 – 7 days

If treated with penicillin – chemoprophylaxis before discharge

 

Treat seizures if present

Treat raised ICP

      Fluid restriction

      Mannitol

 

Supportive treatment

Treat septicaemia and shock

      Oxygen

      Ventilation if necessary

      Volume expansion with Ringers or Saline

      Inotropes

DIC

                  FFP

                  Heparin?

Platelets

Steroids controversial – may help in ARDS

 

Adrenal haemorrhage (Waterhouse Friderichsen syndrome)

      Salt and fluid replacement

      Glucose

      Hydrocortisone

 

Notify disease!

 

 

e.                   Discuss primary and secondary prevention of this disease.                              (10)

 

Primary prevention

 

Casular polysaccharide vaccines available against group A,C,Y and W135

Poorly immunogenic against group B

Indicated to control outbreaks, travellers to endemic areas and household contacts

Group B vaccine being developed

 

Secondary prevention

Chemoprophylaxis in

      Infants

Household contacts

Epidemic

Health care workers – e.g. mouth to mouth

Patient, after treatment with Penicillin

 

Rifampicin

Ceftriaxone

 

Ciprofloxacin

Minocycline

 

 

2          A 6-year-old boy presents with a two-day history of swollen legs, having been previously well. His urine is a dark brown colour. He has an inflamed pharynx and healing impetigo on his legs. Urine dipstix reveals blood (4+) and protein (2+). Clinical examination is otherwise normal.

 

 

a)         What is the most likely diagnosis?                                                                                                                                                                 (3)

b)        What is the most likely underlying cause of the condition?                                                                                                                                (2)

c)         List three common complications of the condition.                                                                                                                                  (6)

d)        What investigations would you perform? Provide the reason for each investigation.                                                                                 (9)

e)         Describe your management of this child.                                                                                                                                                  (20)

 

What is the most likely diagnosis?                                                                                                                                      (3)

Acute post-streptococcal glomerulonephritis

What is the most likely underlying cause of the condition?                                                                                          (2)

Streptococcal infection (impetigo)

List three common complications of the condition.                                                                                                         (3)

Hypertension

Pulmonary oedema/cardiac failure

Acute renal failure

What investigations would you perform? Provide the reason for each investigation.                                             (9)

AntiDNaseB antibodies give an indication of recent Streptococcal infection. Anti-streptolysin O titre is less sensitive for skin infections, the usual form of infection causing glomerulonephritis (one mark for ASOT). The presence of healing impetigo and a typical clinical picture in this case means that the serological test may add little additional information.

Urea and creatinine provide information about the adequacy of renal function that is not ascertainable clinically.

Potassium and sodium. Hyperkalaemia is an important complication of renal failure, and cannot be detected clinically.

Chest x-ray, to detect pulmonary congestion or cardiomegaly in this child before overt cardiac failure.

Complement. A low C3 is characteristic, but the finding provides little useful additional information in this case, where post-Streptococcal acute glomerulonephritis appears highly likely.

Urine microscopy. Red cell casts would confirm the diagnosis, but are seldom seen in routinely processed specimens, and the diagnosis of glomerular disease is very likely.

Urine culture. To exclude a urinary tract infection.

Skin or throat culture – organisms may no longer be present on the impetigo, which appears the more likely cause than the current inflamed pharynx.

 

[Award marks for reasons given for not doing a test]

 

Describe your management of this child.                                                                                                                         (20)

Penicillin orally for 10 days, or benzathine penicillin intramuscularly

Monitoring

Daily fluid intake/output

Daily weight

Daily urine dipstix, specific gravity, colour

3-hrly blood pressure

Fluid restriction (formula)

Restrict to 20ml/kg/day plus previous day’s urine output (less if already fluid overloaded)

Food

High carbohydrate diet

Low potassium, low sodium

Low protein diet if urea > 20 mmol/l

Avoid drugs excreted by kidney (NB digoxin)

 

If hypertension were to develop

Frusemide 1-2mg/kg/dose orally 1-3 times daily

Treat hypertensive episodes with nifedipine or hydralazine

 

If circulatory congestion and pulmonary oedema were to develop

Oxygen

Morphine

Frusemide IVI

Rotating tourniquets

Venesection

Peritoneal dialysis

Artificial ventilation

 

If seizures

Diazepam

 

 

 

3          You are called to casualty to see a teenage girl who was found wandering around the streets confused and smelling of alcohol. She has torn clothing, a laceration on her scalp and blood stained panties. The accompanying policeman suspects that she has been assaulted and possibly raped.

 

a)         You need to consider consent to proceed with an examination. What consent do you consider necessary? In the absence of any parent what options are available to you?                                                                                                                                                        (4)

 

b)                 Discuss three possible causes for her confusion and describe how you would manage each of these.                                     (6)

 

Your examination reveals a young girl with confusion but no depressed level of consciousness or neurological deficit. She has stage 4 pubarche, stage 4 thelarche and findings suggestive of rape as you find semen on her thighs and signs of acute genital trauma.

 

c)                 What investigations will you undertake and what treatment will you prescribe?                                                                                         (8)

 

d)                 Do you require consent for any of the above investigations or treatment, and if so what would you do in this instance?             (3)

 

Although her initial HIV Elisa test was negative, a follow up test 3 months later is positive.

 

e)                 In the South African public health sector what are the criteria for prescribing antiretroviral therapy?                                                   (8)

 

f)                   If she does not meet these criteria how would you care for her?                                                                                                              (8)

 

g)                 When and how would you reassess her eligibility for antiretroviral therapy?                                                                                          (3)

 

  1. You need to consider consent to proceed with an examination. What consent do you consider necessary? In the absence of any parent what options are available to you?                                                               (4)

 

Consent from the child.

AND

Consent from the parent or guardian.

If, in a case of suspected child abuse, this is refused consent should be obtained from the police – SAP 308 which is consent to examine a person in the event of a suspected criminal offence.

In the absence of a parent proceed with police consent – SAP 308.

 

  1. Discuss three possible causes for her confusion and describe how you would manage each of these.                                                             (6)

 

Intoxication:

Rehydrate.

Monitor blood glucose.

Observe and give it time.

Head injury:

            Neurologic examination.

                        Focal signs or depressed level of consciousness – CT scan head.

            Neurological observations.

            Appropriate management for cerebral oedema if indicated.

Post traumatic stress disorder:

            Debriefing.

            Review in 1 – 2weeks and consider ongoing counselling.

 

Your examination reveals a young girl with confusion but no depressed level of consciousness or neurological deficit. She has stage 4 pubarche, stage 4 thelarche and findings suggestive of rape as you find semen on her thighs and signs of acute genital trauma.

 

  1. What investigations will you undertake and what treatment will you prescribe?                                                                                                         (8)

 

Investigations:

            WR, Hepatitis B, HIV & pregnancy test.

            If HIV test is negative also requires FBC, U&E & LFTs.

 

            STI prophylaxis:

Rocephin – 250 mg IMI stat

Erythromycin      250 mg qid for 14 days

Flagyl 200 mg tds for 10 days

            Pregnancy prophylaxis –

Ovral 28 two tablets stat 7 two in 12 hours

Maxalon 10 mg po tds prn for 24 hours

            If HIV test –ve: AZT & 3TC according to weight & surface area size            for

            4 weeks.

           

  1. Do you require consent for any of the above investigations or treatment, and if so what would you do in this instance?                        (3)

 

Consent required for HIV test.

Consent required for off label use of ART in PEP of HIV exposure.

As this is a potentially life threatening situation, possible exposure to HIV, and parents are not available to give consent use commissioner’s or medical superintendent’s consent.

 

Although her initial HIV Elisa test was negative, a follow up test 3 months later is positive.

 

  1. In the South African public health sector what are the criteria for prescribing antiretroviral therapy?                                                              (8)

 

South African birth certificate.

One identified caregiver.

Demonstrated reliability.

Supportive social environment.

Clinical eligibility

            2 or more admissions or 1 prolonged admission for HIV related

problem in previous year.

            CD4 of <20% if under 18 months old and <15% if over 18 months old.

            WHO stage 2 or 3 disease.

 

  1. If she does not meet these criteria how would you care for her?      (8)

 

Holistic approach to HIV infected child and her family, ideally in a multidisciplinary setting.

            Education and ongoing counselling.

Nutritional support with both macro & micronutrient supplements, especially Vit A supplements (200 000 IU every 6 months)

Deworm if appropriate.

Ensure immunisations covered and consider annual ‘flu vaccine.

Promote good hygiene practices – environmental, food preparation, dental & personal hygiene.

Positive living – balance exercise & rest, avoid toxins (especially alcohol & nicotine), reduce stress.

Prophylactic cotrimoxazole when symptomatic or CD4 count down.

Treat inter current illnesses early and appropriately, preferably on an outpatient basis.

 

 

  1. When and how would you reassess her eligibility for antiretroviral therapy?                                                                                                 (3)

 

Correct social circumstances to ensure these meet the requirements.

Reassess clinical status on an ongoing basis and formally every 6 months

Review CD4 count every 6 months.

 

 

4          Sibusisu Mgwali is a 3-year-old boy with a two-week history of increasing dullness and listlessness. He has neck stiffness. He is able to respond appropriately to simple verbal commands. There are no focal neurological signs or papilloedema.

 

No CT Scan is available in your hospital. A lumbar puncture is carried out and the following results obtained:

 

Cells –  Red Cells                           15 cells/mm3

            Lymphocytes                                              270 cells/mm3

            Polymorphs                                     120 cells/mm3

Chem - Protein                                1.1 g/l (N 0.2-0.4)    

            Pandy test for Globulin + ve       

            Glucose                                            1 mmol/l (N ~3-5 [~ ⅔Blood level])

Chloride                                            102 mmol/l (N 116-130)

 

 

a)         What are valid contraindications to doing a lumbar puncture in a child?                                                                                                  (4)

 

b)                 TB Meningitis is a possible diagnosis. Postulate two other possible diagnoses and describe two clinical signs or special investigations that you could use to confirm or refute each of these alternate diagnoses.                                                                (6)

                                                     

c)                 You confirm that Sibusisu has TB Meningitis. Describe your initial therapeutic approach.                                                            (10)

 

d)                 List three complications of TB Meningitis, and explain the pathophysiological mechanism for each.                                                      (9)

 

e)                 Considering his clinical condition, what would you estimate Sibusiso’s chances of full neurological and cognitive recovery to be?                                                                                                                                                                                                                        (2)

 

f)                   What is the likely route whereby the tuberculous bacillus gained entry into the CSF? How was the infection likely to have been acquired?                                                                                                                                                                                                                   (5)

 

g)                 What strategy(ies) could you propose to

 

i)          Prevent children developing TB Meningitis.                                                                                                                                (2)

ii)         Detect it before neurological findings are irreversible.                                                                                                                 (2)

1                    Complications that might be expected

a.       Hydrocephalus                                                             (1)

(Communicating) Obstruction of drainage by arachnoid villi due to high protein / inflammatory response

(Non-communicating) Obstruction of drainage from 4th  ventricle by local inflammatory response and coagulation in CSF of this area.

b.      Inappropriate ADH secretion                                        (1)

Inflammatory response direct effect leading to increased ADH secretion or increased renal sensitivity to ADH.

c.       Cerebral vessel vasculitis                                               (1)

Perivascular inflammation leading to vasculitis and obstruction to blood flow

d.      Seizure                                                                         (1)

Local inflammation, tissue damage from hypoxia, peri tuberculoma inflammation, sodium abnormalities, hypoglycaemia from starvation, cerebral oedema.

e.       Cerebral salt / water wasting                                         (1)

Unsure ? Increased Atrial Natriuretic Peptide secretion, ? direct neural effect on renal function

f.        Later mental retardation or focal neurological fall out      (1)

Local cerebral tissue damage from any or all of the above

 

Any 3 of the above plus a reasonable explanation (2marks each)  where known for the complication.

 

2                    He is able to respond and has no focalizing or lateralizing signs but has signs of meningeal irritation.

 

a.       His classification would be stage 1 (signs of meningeal irritation: fever; lethargy; conscious; rational; no focal neurological signs; no hydrocephalus)

(1)

The underlined findings are present. Rationality is difficult to assess at this age. Hydrocephalus has not been excluded – but not overt. Fever is not mentioned.

 

b.      His chances of full recovery while guarded but reasonably good.

(1)

 

1 mark for assessing the stage in some manner, 1 mark for assessing the outcome as reasonable.

 

3                    The likely route of infection would be:

a.       Exposure to adult open TB                                                                   (1)

b.      Bacillus inhaled and settles in lung                                                          ( ˝ )

c.       Local primary TB infection in child’s lung                                               ( ˝ )

d.      Spread to pulmonary lymph node                                                          ( ˝ )

e.       Spread up lymphatics as intermittent bacillaemia into circulating blood    ( ˝ )

f.        Deposition in brain in parameningeal site                                                ( ˝ )

g.       Progression of small local tuberculoma in parameningeal site                  ( ˝ )

h.       Rupture into CSF                                                                                 ( ˝ )

i.         Reaction to presence of bacilli in CSF (low bacilli load)                         ( ˝ )

 

The above marking or similar.

 

4                     

a.       Preventing TBM in children – sensitise health care workers to:

                                                               i.      Detecting and treating prophylactically children in contact with adults with open TB. In all cases where adults are treated for TB, child contacts should be actively sought and treated.                                         (1)

                                                             ii.      BCG immunization of all children.                                              (1)

                                                            iii.      Active exclusion or detection of TB infection in all children where TB is suspected: (history of contact, clinical signs or symptoms, tuberculin testing, CXR and microbiological testing as appropriate) NB.          (1)

1.      Children with growth faltering, failure or weight loss.

2.      Children with chronic cough.

 

Any 2 of the above or reasonable reference to these

 

b.      Early detection of TBM in children while still successfully treatable – sensitise health care workers to:

                                                               i.      Sensitivity to behavioural/ neurological presentation as possible presentation of TBM.                                                                 (1)

                                                             ii.      Suspicion of TB, and later TBM,  in children with growth faltering/failure.

(1)

                                                            iii.      Early treatment of all cases of likely / possible TBM while the diagnosis is being confirmed. (e.g. in meningitis where the diagnosis is not clear but might include TBM; treat and if later shown not to be TBM treatment may be stopped then)                                                               (1)

                                                           iv.      Lumbar puncture of all children where the diagnosis is reasonably likely and in whom contraindications are not present.                                  (1)

 

Any 2 of the above or reasonable reference to these

5          You are the medical officer at a district hospital. You are concerned about the high mortality in low birth weight babies at the hospital. A colleague suggests that kangaroo mother care may assist in reducing this toll.

 

a)         What are the key components of kangaroo mother care?                                                                                                                            (5)

 

b)                 Under what circumstances is kangaroo mother care particularly beneficial?                                                                             (5)

 

c)                 Tabulate the advantages and disadvantages of kangaroo mother care to the mother, the infant and the hospital.                             (15)

 

d)                 Describe how you would establish a kangaroo mother care unit in your hospital?                                                                      (15)

 

 

a. What are the key components of kangaroo care?                                                    (5)

 

The key components of kangaroo care are that -

  • The child and mother are in almost constant skin-skin contact
  • The body heat of the mother is used to warm the infant
  • The breathing of the mother is used to stimulate the infants respiration
  • The infant is dependant on the mother’s own milk and later breast feeding
  • The contact between mother and child promotes bonding.

 

b. Under what circumstances is kangaroo mother care particularly beneficial?     (5)

 

Kangaroo mother care is particularly beneficial -

  • In poorly resourced services where there is a shortage of nursing staff and incubators.
  • In transporting newborn babies to referral centres from peripheral clinics.
  • In warming of hypothermic infants.
  • As an adjunct to the management of babies in NICU.
  • In regions with high neonatal and infant mortality rates.

 

c. Tabulate the advantages and disadvantages of kangaroo mother care to the mother, the infant and the hospital.                                                                                         (15)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Advantages

Disadvantages

Mother

Promotes bonding

The siblings may have nobody to care for them

 

She has time to recover from the birth without having to take up the responsibility of running a home as well as caring for the baby.

Some women need to return to work for financial reasons.

 

She has an opportunity to establish breast feeding

Mother’s who have AIDS may decide not to breast-feed.

 

Mothers become more confident in the care of their babies. This allows for earlier discharge.

 

 

The volume of breast milk has been found to increase with skin-skin contact

 

Baby

The rate of infection is reduced by colonization of the infant with the mothers own skin flora.

 

 

Improved cardio respiratory stability

 

 

Babies grow and develop faster.

 

 

Decreased mortality rate.

 

Hospital

Infants can be moved out of the incubator earlier, these reduce hospital expenses and the load on staff.

Setting up and staffing such a unit requires allocation of both staff, money for equipment, time to train staff and a space.

 

Earlier discharge cuts patient loads and costs.

 

 

Improved relationships between mothers and staff.

 

 

Better survival – Third world

 

 

Better care  - First world

 

 

 

 

 

 

d. Describe how you would establish a kangaroo mother care unit in your hospital.

 

The technique of kangaroo mother care consists of placing the naked baby on the mother’s chest and holding it there firmly with a cloth until it is ready for discharge.

The complexity in setting up KMC is to establish an environment in which this can take place.

 Initially the hospital management will need to be convinced that there is a benefit to  both the hospital and the community in establishing such a unit.

  • Discuss the benefits and challenges in establishing such a unit.
  • Establish what costs would be involved and what cost benefits there would be to the hospital.
  • Establish the benefits and disadvantages there would be to the particular hospital and community.

Once the concept has been adopted and agreed to by the hospital, the hospital then needs to establish a comprehensive plan involving all stakeholders including the community. The media can be used to inform the community and antenatal clinics to teach mothers about the concept at the first visit.

The practical aspect of establishing the unit will involve finding a suitable area to where the mothers can stay, nursing staff to run the unit and funding for equipment such as extra beds, food for the mothers, etc.

The staff working in the unit will need to be trained. There also needs to be buy in from all the hospital departments such as obstetrics, ICU and ANC with the development of protocols, which will allow for the progression of care.