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Diploma
in Child Health (DCH [SA])
Examination
Candidate
Guidelines
The
§
Written examination (two three-hour papers)
§
Objective structured clinical examination (OSCE): also
called the Comprehensive Paediatric Clinical Skills Assessment (CPCSA)
§ Slide test
A. Syllabus
The Diploma
in Child Health is designed to give recognition to competence in the care of
children to general practitioners, community service doctors and medical
officers who have trained in paediatrics and child health.
- The examination is not
designed to test detailed knowledge of the in-patient care of children,
nor minutiae of management of rare conditions.
- Practitioners in the
community should have an understanding of hospital paediatrics to enable
them to know when to refer and what to expect.
- Hospital practitioners
should have a good understanding of social and community paediatrics and
of other services in order to facilitate improved communication and an
integrated child health service.
The aim is
to test primary care paediatrics, particularly the following aspects:
(a) Diagnosis, management, epidemiology and prevention
of common and important acute and chronic medical, surgical and psychological
disorders of childhood; with particular reference to their management and
primary care.
(b) Principles of health surveillance;
(c) Normal
physical, mental and emotional growth and development.
(d) Minor
paediatric abnormalities and their management.
(e)
Prenatal and perinatal care as it affects the subsequent progress of the
infant.
(f) The
care of the newborn.
(g) The early detection of abnormalities and their
management, including genetic counselling.
(h) Promotion of child health, health education,
immunisation and screening procedures and their evaluation.
(i) Infant
feeding and nutrition.
(j) The effects of social environment on child health,
including accidents and child abuse.
(k) Assessment and long term management of children
with chronic illness, disabilities and children with special needs.
(l)
Principles of co-operation with social agencies.
(m) Adoption,
fostering and legislation relevant to children.
(n) Principles of educational medicine. Educational and other problems in normal and special schools.
Candidates
are required to have completed a minimum of six months hospital
experience in Paediatrics and Child Health before sitting the examination as it
is unlikely that a candidate would be successful without this experience.
B. The Examination
Written Examination
The
Written Section consists of the following two sections:
a) Written
Paper I (3-hour paper)
- 20 short
notes type questions
b) Written
Paper II (3-hour paper)
- 5 case-scenario-based
short answer questions
Paper 1
(Short answer questions)
Instructions:
- Answer each of the following FIVE (5)
questions in separate books.
- Each question has 4 sub-questions. Answers to
each sub-question should be approximately 100-150 words (not more than 1
page) in length. Each sub-question is worth 5 marks. The whole paper is
worth 100 marks.
- The aim is to check your ability to express
objective knowledge with precision. Each question has a standard model
answer and the marks awarded depend on the number of correct points
mentioned matching the model answer.
Examples:
a) Consent to medical
treatment in children.
b)
The typical cerebrospinal fluid (CSF) findings in tuberculous
meningitis.
c)
Clinical presentation and
management of tinea capitis.
d)
Approach to a well 6-week-old child who presents with
persistent conjugated hyperbilirubinaemia
e)
Advice you would offer to
parents on toilet training their child.
Paper 2 (Scenario-based
questions)
Instructions:
- Answer each of
the following FIVE (5) questions.
- Each question
to be answered in a separate book.
- Each question is worth
40 marks. The whole paper is
worth 200 marks.
Example:
A
professional nurse at a nearby clinic refers Linda, an 8-month-old girl, to
your hospital. The nurse’s diagnosis is “Severe Pneumonia” according to the
Integrated Management of Childhood Illness (IMCI) guidelines. Linda’s mother
tells you that Linda was well until last night when she developed a cough and a
noisy chest. Since this morning she has not been feeding and feels hot.
Examination
reveals a normally grown girl with an axillary temperature of 38oC,
a respiratory rate of 60 breaths per minute, a pulse rate of 130 beats per
minute, chest in-drawing, a 4 cm soft liver (displaced downwards), loss of cardiac dullness on percussion, and crackles and
wheezes over most of the chest. Linda appears lethargic and grunts with
expiration. She is neither pale nor cyanosed. Other findings are normal.
a) How
severe is the respiratory condition in this child? Motivate your answer. (6)
b) Based on the above clinical
findings, what is the most likely pathophysiological
diagnosis, and the THREE most likely aetiological agent(s)? (5)
c) Indicate TWO differential
diagnoses that you would consider, but exclude, and indicate for each why you
have not made it the most likely diagnosis. (6)
d) List THREE special
investigations would you carry out and describe the value of each
investigation. (6)
e) Provide a pathophysiological
explanation for the “chest in-drawing” and explain what information it gives
concerning this child’s condition. (4)
f) Explain the mechanism for
“grunting” in children with respiratory disease and its significance in this
child. (3)
g) How would you treat this child and
explain each therapy’s mechanism/mode of action. (10)
Candidates
must obtain a mark ≥45% in Written Papers I and II combined, to qualify for the Clinical Section.
Clinical Examination:
Comprehensive Paediatric Clinical Skills
Assessment (CPCSA)
Introduction
As
from September 2006 the
This proposal provides an
overview of the proposed CPCSA clinical examination, in terms of what it will
mean for the candidates.
The CPCSA carousel
§
The CPCSA examination consists of five (or six)
clinical stations, each assessed by one independent examiner.
§
Candidates will start at any one of the five (six)
stations, and then move round the carousel of stations, at 15-minute intervals with
a five minute break in-between, until they have completed the cycle.
§
A full cycle of five candidates will be completed in 95
minutes (75 minutes examination time and 20 minutes for movement between
stations))
Written
instructions
For each case at the
clinical stations, the candidate will receive written instructions as to what
is required of him/her (Example 1).
|
Example
1: Example of written instructions to the candidate at the cardiovascular
station This
2 year old girl is thought to have a heart murmur. She is having difficulty
finishing feeds, sweats a lot and is tired all the time. Please examine the
cardiovascular system and tell the examiners what signs you find, and discuss
your proposed management. |
Clinical
Stations 1, 2 and 3
These clinical stations
are similar to the current short cases in many paediatric undergraduate
clinical examinations in their objectives, namely, to assess the candidate's ability to
examine the child, interpret physical signs and discuss the case.
Competence
in examination technique, ability to elicit abnormal findings or their
absence, and ability to discuss their significance will be
assessed.
The
key features are as follows:
§
all clinical examinations will be observed
§
there are written instructions for each case (see Example
1)
§
there is a set time limit for each case (15 minutes)
§
a set period (5 minutes) will be assigned for discussion
§
every candidate on the carousel will be examined by the
same examiner at each station
§
each examiner has a structured mark-sheet for the case
The three clinical stations will present children
with a variety of common clinical problems from the various body systems, e.g.
Station 1 could be a child with pneumonia, Station 2 a child with cerebral
palsy and Station 3 a child with hepatosplemomegaly.
Clinical
Station 4
The history taking skills station aims to
assess the candidate's ability to gather data from the child’s parent/caregiver,
to assimilate that information and then discuss the case.
Key
features of this station are:
§
written instructions for the
case, usually in the form of a letter from the primary care clinic (or child's
GP) are given to the candidate during the five minute interval before the
station. (Example 2)
§
10 minutes are allowed for the history taking, followed by
five minutes for discussion with the examiner (after the parent/caregiver has
left the station)
§
the examiner is present throughout, observing the history
taking
§
each examiner has a structured
mark-sheet for the case (marks for key questions that candidate should have
asked).
Example
2: Example of written instructions to the candidate at the history taking
station
|
Instructions
to candidate: Please read the letter from this child’s primary health care
clinic and then conduct an appropriate consultation with the child’s
parent/caregiver. You are not expected to examine the child. Dear
Doctor This
4-year-old asthmatic child has developed worsening symptoms despite salbutamol
and beclomethasone inhaler therapy. He is generally well apart from a
worrying skin rash. She has a past history of ……... I would be grateful for
advice on her further management. Yours sincerely, Sr. Skosana (RN) |
Clinical
Station 5
The communication skills and ethics station aims to assess the
candidate's ability to guide and organise the interview with the standardised subject
(who may be a child, parent, relative, or surrogate), provide emotional support
and discuss further management. Written instructions for the case will be given
to the candidate during the five minute interval before this station (Examples 3
and 4)
Example
3: Example of written instructions to the candidate at the communication
skills station
|
Instructions
to candidate: This 18-month old child is about to leave hospital, nineteen
days after being admitted with severe malnutrition. Her 23-year-old, single
unemployed mother is uncertain about what she needs to do at home to prevent
a relapse of her child’s condition and what help is available to ensure that
she has enough food to feed her child. What
advice would you give her on the further management of the
child’s condition? You are not expected to examine the patient. |
Key
features of this station are:
§
the examiner is present throughout
§
10 minutes are allowed for the interaction between
candidate and subject (parent), followed by five minutes for discussion with
the examiner (after the subject has left the station)
§
each examiner has a
structured mark-sheet for the case.
Example
4: Example of written instructions to the candidate at the ethics/communication
station
|
Instructions
to candidate: You are about to see
Susan Kekana, the mother of a newborn infant who has experienced severe birth
asphyxia. You are the doctor responsible for the baby. The baby has been on a
ventilator for 48 hours, with no improvement, and shows evidence of severe
neonatal encephalopathy. You believe that withdrawal of ventilation may be
appropriate. Susan
has requested the meeting with you to discuss her baby’s condition and your
plans for the baby. |
Clinical
Station 6
Clinical station will require the candidate to
demonstrate various skills, such as developmental assessment, vision and
hearing screening, resuscitation, i.e. a series of three or four skills. The
station may contain more than one patient (e.g. a newborn, one-year-old and
four-year-old child) and include both normal children and children with
developmental or sensory deficits, and models. Table 1 includes examples of
skills that may be assessed (the list is not comprehensive).
Table 1: Examples of Skills that can be assessed
|
Skill |
Activity |
|
Vision screening and
testing |
Ophthalmoscopy
skills (red reflex, cataract) Squint assessment
(Cover test) Testing of visual
acuity (child > 3 years) |
|
Hearing screening
and testing |
6-12 months distraction test of hearing Essential features for 18-30 months test of
hearing, e.g. recognition of familiar objects Essential features for 2˝ - 3˝ years test of
hearing, e.g. performance/conditioning test, speech discrimination |
|
Language development |
Comment on comprehension, expression and
articulation. |
|
Developmental
screening |
Elicit a
developmental history Assess the
developmental age of a child |
|
Resuscitation skills |
Neonatal
resuscitation Infant or child
resuscitation Basic CPR (e.g.
drowning) |
|
Anthropometrics and
Growth |
Weight, height, head
circumference measurement Plotting on charts Interpretation of
charts |
|
Bedside clinical
procedures (may involve use of models) |
Hand washing Lumbar puncture Umbilical
catheterisation |
|
Ear examination |
Otoscopy skills |
|
Skin rash |
Description and
recognition of a skin rash |
|
Neonatal examination |
Gestational age
assessment, primitive reflexes |
|
Bedside lab
procedures |
Stool lactose test,
urine test |
Advantages of CPCSA over the previous DCH (SA)
Clinical Examination
More
standardised and objective assessment of the candidate's examination skills
- direct assessment of the candidate's ability to elicit
a history and to communicate with the child or his/her caregiver.
- detailed feed-back of performance to those candidates who
fail.
- increased validity and reliability of exam
(multiple cases/skills assessed)
Table
2: Example of CPCSA exam stations
|
Station 1 |
Respiratory system
examination, or Cardiovascular system
examination (15 minutes) |
|
Station 2 |
Abdominal system
examination, or Reticuloendothelial
system examination (15 minutes) |
|
Station 3 |
Central nervous system
examination, or Other (general) system
examination (15 minutes) |
|
Station 4 |
History taking skills (15
minutes) |
|
Station 5 |
Communication skills, or
ethics (15 minutes) |
|
Station 6 |
Clinical skills
(Resuscitation, growth assessment, developmental assessment) (15 minutes) |
The
examination centre will provide standard equipment appropriate to the
examination, but candidates may bring any suitable equipment that they are
familiar with. Candidates should bring their own stethoscope.
A child-friendly approach is expected at all
times. Candidates will not be penalised if a child cries or becomes upset
during the examination, provided that this is not the
consequence of the candidate’s technique. The candidate’s
general approach and attitude toward the child and caregiver is important and
will be noted. Aggressive or inconsiderate behaviour, either physical
or verbal towards a child or his/her family will almost invariably result in
failure
Slide test
This component
usually lasts 90-120 minutes and consists of 10-20 questions.
It may be
computer-based or paper-based.
The slide test
assesses identification of signs, interpretation of these and of other common
investigations, and the management of common paediatric conditions.
C. Mark
allocation
§
Written Paper
§
Written Paper
§
Comprehensive Paediatric Clinical Skills Assessment
[CPCSA]: 60%
§
Slide test: 10%
Last amended: 29
June 2006