Diploma in Child Health – August 2007

P1Q1:

a)      List clinical features suggestive of child abuse (non-accidental injury).

 

·          “Frozen watchfulness” / Abnormal child parent interaction

·         Injuries incompatible with history

·         Injuries incompatible with stage of development

·         Bruising or abrasion with any of following characteristics

Multiple bruises at different sites

Bruises of different ages

Well demarcated linear bruises corresponding to known objects

Parallel “tram track” lesions from whipping with stick or cord

Black eyes, when bilateral

Teeth marks

Bruises on legs if child not yet walking

Bruises to face and neck

·         Burns

Glove and stocking burns of hands and/or feet

Circular burns (cigarettes)

Any well demarcated burn without adequate explanation

·       Hair loss , bruised or swollen ears and torn tympanic membranes

·       Multiple scars, abrasions, or scratches in different stages of healing

·       Circumferential injuries of ankles, wrists and neck

·         Sub-conjunctival, anterior chamber  and retinal haemorrhages

·         Unexplained altered level of consciousness

·         Signs of ruptured abdominal viscus

·         Genital or anal injury

·         Multiple or unusual fractures

 

b)      Annotate the clinical features, diagnosis, and treatment of an infestation with Ascaris lumbricoides (roundworm).

 

·         Clinical features

Asymptomatic

Ill defined abdominal discomfort

Colic, Intestinal obstruction, Volvulus

Worms migrating into orifices causing obstruction of

Appendix, bile and pancreatic ducts

Large numbers may interfere with appetite, digestion and absorption contributing to malabsorption

Lung: Wheezing, possible aggravation of asthma

·         Diagnosis

Seeing passed worms

Stool microscopy - eggs

Plain abdominal x-rays

Show worms, obstruction or volvulus

In rare instances

If in biliary tract – ultrasound or cholangiography

Barium meal

·         Treatment

Piperazine, mebendazole, albendazole or pyrantel

 

 

c)      Discuss the management of enuresis (bedwetting)

 

·         Assume organic cause if nocturnal and no other urinary symptoms

·         The older the child, the more active the intervention

Consider treatment only after 5 years of age

·         Tendency to spontaneous cure

·         Exclude and manage disturbed family setting or underlying psychopathology as cause

·         Education and reassurance of  parents to relieve tension

Mainstay of treatment

·         Avoid coercion or punishment

·         Understanding and symptomatic approach

·         Increase bladder capacity

Drinking large quantities early in day – holding urine

·         Self training to wake up when full bladder

·         Reduction of fluid in evening

·         Reward system

·         Bell and pad system

·         Imipramine

Side effects and relapse common

In isolation unlikely to provide cure

Danger of accidental poisoning

·         In very resistant cases DDAVP

Expensive

 

 

d)      Outline reasons why a child with pneumonia may fail to respond to usual therapy.

 

·         Incorrect choice of antibiotic

·         Inadequate dose  of antibiotic/ antibiotic not taken

·         Pneumonia not caused by suspected organism

Pneumonia caused by Mycobacterium tuberculosis

Other bacteria

·         Organism resistant to antibiotic used

·         Development of empyema or other complications

·         Suppressed immunity

HIV

Other causes

·         Underlying cause

Foreign body aspiration

Bronchiectasis

Cystic fibrosis

·         Left sided cardiac failure masquerading as pneumonia

[40]

 

Q2:

 

a) As the doctor in charge, describe how you would organise the triage, assessment

and treatment of children in a busy outpatient department in a district hospital to

maximise efficient and effective service delivery.

 

Answer:

Importance:

§         30-60% of deaths in South African hospitals occur in the 1st 24 hours

§         Often children are not checked by experienced child healthcare workers as they arrive, and may sit in the queue for hours before being seen

§         Children may deteriorate or die of treatable conditions while sitting in the queue

Organising a busy OPD:

§         Requires sorting of patients  into priority groups according to their need, and according to local resources available: this is triage

§         Once triaged, children must be managed according to their category

Categories

§         Children with EMERGENCY signs: emergency signs are of problems with Airway and Breathing, Circulation, Consciousness and Convulsions, and severe Dehydration. These children require IMMEDIATE emergency treatment

§         Children with PRIORITY signs: examples of priority signs include age < 2 months, very high temperature, trauma, severe pallor, poisoning, severe pain, respiratory distress, restlessness, irritability, lethargy,  malnutrition, burns, etc. These children require rapid assessment and treatment (before the non-urgent cases)

§         Non-urgent cases have no emergency or priority signs, and can wait their turn in the queue on a first come first served basis.

Process

§         Triage must occur when children first arrive in the OPD, before administrative procedures

§         Triage should not take a long time (20 seconds for children without emergency signs)

§         All staff in the OPD setting should be competent in triage, and there should be a designated staff member responsible for triage at all times

§         Children identified with emergency signs must be taken immediately to the emergency room

§         Children with priority signs must be placed in a priority queue

§         Clinical staff should be allocated to emergencies, then priority conditions, then non-urgent cases

§         Achieving this requires reviewing and revising patient flow, and floor plans.

 

THE MAIN POINT IS THAT SICK CHILDREN MUST BE IDENTIFIED AND CATEGORISED AS SOON AS THE ARRIVE IN HOSPITAL. THE SICKEST MUST BE ATTENDED TO IMMEDIATELY, OTHERS MUST BE PRIORITISED, AND NON-URGENT CASES WAIT.

 

b) For children to receive a comprehensive HIV care plan, they need a comprehensive

HIV assessment. What are the components of a comprehensive HIV assessment?

History:

§         maternal antenatal testing (HIV serology, and CD4), and antenatal and perinatal ART (HAART/NVP)

§         the child’s perinatal ART experience

§         history of childhood sexual abuse, or other HIV exposure

§         infant feeding choice and practice

§         Cotrimoxazole

 

Testing:

§         maternal testing and results (HIV serology and CD4) and age of child at the time of the test, remembering that positive serology under 18 months indicates HIV exposure NOT infection

§         paternal testing and results (HIV serology and CD4) and age of child at the time of the test

§         the child’s test: serology and age at test, PCR and age at test, and relation to breast feeding cessation

§         child’s CD4 if indicated

 

Staging

§         All HIV infected children must be staged clinically according to the modified WHO staging system for South Africa

 

Place of HIV care

§         The site at which the family CURRENTLY receives care must be identified

 

HAART History

§         Eligibility for, initiation of, and administration and monitoring of HAART must be ascertained

 

Documentation

§         All above components must be clearly and accurately documented

 

Assessment

§         Misleading euphemisms (like RVD +) must NOT be used

The assessment includes: the laboratory status (HIV exposed or HIV infected), the clinical stage, the CD4 count, as well as eligibility for further testing (PCR if HIV exposed, or CD4 if not done yet), and HAART status

 

c) Tabulate the different oxygen delivery systems for children available at clinics and

district hospitals, and the advantages and disadvantages of each method (system).

 

 

Method/System

Pros

Cons

Nasal catheter 1: made from feeding tube (FG5/8) with end tied and  two holes cut, strapped with holes below and adjacent to the nostrils; connect to an oxygen point with a flow of 1- 2l/min

The child can be moved, cuddled, breast fed, fed, if not otherwise indicated

Works loose if not strapped well; if the nose becomes blocked, oxygen delivery falls off; mouth-breathing occurs when the child cries, with oxygen delivery fall-off; may not achieve adequate FiO2

Nasopharyngeal catheter 2:

Use an 8 FG size tube, Measure the distance from the side of the nostril to the inner eyebrow margin with the catheter, insert the catheter to this depth,  secure with tape, connect to an oxygen point with a flow of 1- 2l/min

Ditto

Can be mistaken for a naso-gastric tube, with the feed then being given into this tube, causing choking and / or aspiration pneumonitis; may not achieve adequate FiO2

Nasal Prongs: use manufactured prongs (prong size appropriate to child size) with the prongs strapped into the nostrils; prong length can be shortened fo comfort; connect to an oxygen point with a flow of 1- 2l/min

Ditto

Easy to use; delivers higher FiO2 than catheter systems

Prongs can cause excoriation of the nasal septum (and epistaxis); may not achieve adequate FiO2; if the nose becomes blocked, oxygen delivery falls off; mouth-breathing occurs when the child cries, with oxygen delivery fall-off

Face mask: 28, 40 & 60% masks are available (and adjustable concentration masks; use a size appropriate to the child’s size; flow should be as indicated on each mask for desired concentration

Not many pros in paediatrics

The masks are uncomfortable, rarely fit well; and often fall off; the child cannot breastfeed, nor be fed without a nasogastric tube

Headbox: correct flow is 2l/kg/min, minimum flow is 5l/min

Can deliver high FiO2

Restricts movement; the child cannot breastfeed, nor be fed without a nasogastric tube; in neonates too high oxygen concentration may be delivered causing ROP, contributing to BPD; low flow leads to CO2 buildup; uses large quantities of oxygen (expensive)

Nasal prong CPAP: needs prongs, specialised circuit, and flow/pressure driver

Can deliver high FiO2, and alveolar distending pressure, life-saving and IPPV-sparing, should be present in all district hospitals especially for neonates

May be difficult and dangerous to feed the child even by NGT, prongs can case; can be tricky to use; use limited to neonates and small infants

Mechanical Ventialition

Life saving, while awaiting transfer to higher level of care

Dangers include dislodged and blocked ETT’s and barotraumas (air leaks, BPD in neonates)

 

 

 

Oxygen supply

 

 

Piped

Gold standard

 

Bottle

Can get anywhere

Often empty before replacement arrives, heavy, unwieldy, valves difficult to manage

Concentrator

Excellent where no piped or bottled oxygen; more reliable than bottled oxygen

Electricity reliant, limited maximum FiO2

 

 

d) Outline measures that can prevent the occurrence of rheumatic heart disease in a

community, and measures that can reduce morbidity in a child with established

rheumatic heart disease.

 

Prevention of occurrence:

§         Political: Tackle poverty

§         Social: Tackle overcrowding

§         Medical: all children with sore throats from the ages of 3 – 15 years should receive penicillin (IM or oral for 10 days) or erythromycin for 10 days if penicillin allergic.

 

Disease surveillance

§         Acute rheumatic fever must be notified, which assists with knowing the size of the problem at a population level, so that resources can be appropriately allocated for prevention and management

 

Prevent/Reduce Morbidity

§         Once an episode of acute rheumatic fever has occurred, the most important intervention is to ensure proper monthly follow up for penicillin injections. The patient and caregiver must understand this, and the importance of NEVER GETTING ACUTE RHEUMATIC FEVER AGAIN

§         All patients with rheumatic heart disease, and Sydenham’s Chorea, must be followed up in a cardiology service. Then:

o       Level 1: for monthly penicillin, and other treatment

o       Level 2: for cardiac assessment, 6 monthly to annually

o       Level 3 if: for long term planning at disease onset, and if heart valve replacement is a possibility

§         Ensure that the caregivers understand:

o       The severity of the valve damage is variable. If it is mild, following the acute rheumatic fever episode, the child is LUCKY, and a repeat episode of ARF must never be allowed to happen

o       Monthly penicillin (or erythromycin) must continue until 35 years

o       At puberty, planned parenthood discussions must begin. Pregnancy is a potentially lethal condition in children with rheumatic heart disease

o       Care dependency grants may be warranted, depending on the degree of disability

§         If a child with established rheumatic heart disease, the possible reasons are as follows, and must be diagnosed rapidly:

o       Another episode of acute rheumatic fever (due to failed prophylaxis): Check the diagnostic criteria (Jone’s)

o       Infective endocarditis: Look for the classic signs, but especially pyrexia, splenomegaly, haematuria, leucopaenia and do three blood cultures within 1 hour, before starting antibiotics

o       Precipitous myocardial failure (irreversible – apoptosis, reversible – treatment problem): Find out about adherence, and check previous myocardial function

o       Valve stenosis, especially mitral: Critical mitral stenosis is life-threatening and if present needs to be attended to URGENTLY. Check for a loud S1, a long diastolic murmur at the apex and severe LAH on ECG. If in doubt, refer

o       A non-cardiac condition (e.g. severe ARI, APSGN, pregnancy)

o       Look for the cardiac causes AND think about others

 

 

Q3:

 

a)      Outline the principles and goals of treatment of children who are overweight.

 

Five guiding principles are important for the treatment of overweight, which can be summarized as follows:

  1. Establish individual treatment goals and approaches based on the child's age, degree of overweight, and presence of comorbidities.
  2. Involve the family or major caregivers in the treatment.
  3. Provide assessment and monitoring frequently.
  4. Consider behavioral, psychological, and social correlates of weight gain in the treatment plan.
  5. Provide recommendations for dietary changes and increases in physical activity that can be implemented within the family environment and that foster optimal health, growth, and development.

The goals of treatment for children who are overweight may include:

·         Weight stabilization (or loss in some)

·         Improved fitness

·         Improved psychological status

·         Improved social functioning

·         Adoption of life-long nutritional and physical activity habits

·         Diagnosis and treatment of comorbid conditions

 

 

b)      Classify and provide examples of risk factors for paediatric hearing impairment.

Classification of hearing impairment

 

  1. Type of hearing loss:
  • Sensorineural: refers to any abnormality of sound transmission beyond the oval window
  • Conductive: refers to a disruption of the passage of sound from the external canal to the oval window

 

  1. Aetiology:
  • Non-syndromic: genetic changes – autosomal dominat or recessive, mitochondrial, X-linked
  • Syndromic

 

  1. Degree of hearing level affected
  • Mild: between 15 and 40 dB
  • Moderate: between 41 and 55 dB
  • Moderately severe: between 56 and 70 dB
  • Severe: between 71 and 90 dB
  • Profound:  91 dB or grater

 

Risk factors for paediatric hearing impairment

 

  • A family history of hearing impairment
  • A birth weight of less than 1500 g
  • Congenital craniofacial anomalies
  • Perinatal infections (e.g. CMV, rubella, herpes, toxoplasmosis, syphilis)
  • Hyperbilirubinaemia requiring exchange transfusion
  • Apgar scores of less than 5 at 1 min and less than 7 at 5 min
  • A requirement for mechanical ventilation for 5 days or longer
  • Head trauma
  • Exposure to ototoxic agents

 

c) List conditions that mimic epilepsy in children, and outline the differentiating

feature(s) of each disorder.

 

Disorders with altered consciousness

  • Apnea and syncope
  • Breath-holding spells
  • Cardiac dysrhythmias
  • Migraine

Paroxysmal movement disorders

  • Acute dystonia
  • Benign myoclonus
  • Pseudoseizures
  • Shuddering attacks
  • Spasmus mutans
  • Tics

Sleep disorders

  • Narcolepsy
  • Night terrors
  • Sleepwalking

Psychologic disorders

  • Attention deficit hyperactivity disorder
  • Hyperventilation
  • Hysteria
  • Panic attacks

Gastroesophageal reflux (Sandifer's syndrome)

 

d) List the diagnostic criteria (clinical, laboratory and radiological) for tuberculous

meningitis (TBM).

 

Clinical

  • history of contact with tuberculosis
  • onset may be gradual with vague complaints of headache, irritability, weight loss and drowsiness
  • later symptoms are convulsions and neurological fall out
  • older children may present with behavioural changes
  • examination may reveal sings of meningeal irritation and raised intracranial pressure, cranial nerve palsies, localizing sings (hemiparesis), altered level of consiousness/coma
  • degree of involvement is classified into 3 stages
  • a Mantoux test must be done and is often negative

 

Laboratory

  • CSF changes (usually protein raised, chloride and glucose low, lymphocytes predominate, Gram stain is negative, AFB seldom found, bacilli may be cultured what take up to 4-6 weeks)

 

Radiological

  • CT scan of the brain: meningeal basal enhancement, hydrocephalus, infarct
  • CXR is often negative

Q4:

 

a) A poorly controlled diabetic mother has delivered a baby. List conditions, problems

or events (other than hypoglycaemia) that you would look out for, or anticipate, in

this infant.

The following are seen in infants of badly controlled diabetic mothers.

Diabetic embryopathy

Caudal regression syndrome

Cardiac and CNS may also occur

Large size of the baby leads to problems with labour ie clavicle, humerus fractures, shoulder impaction, delayed second stage and thus asphyxia,

Late fetal death occurs more frequently

Preterm delivery is common due to fetal distress or planned early delivery thus have HMD etc

Hypoclacaemia

Hyperbilirubinaemia

Polycythemia and all its problems

Lethargy, hypotonia and poor feeding

 

 

 

b) The mother of an 8-month-old boy complains that she cannot feel his testes. List

possible reasons for this, and present your approach to the problem.

4 b)     Is this a male?

            Retractile testes

            Ectopic testes

            Undescended testes

Examine the genitalia,  Has the mother seen testes in scrotum when bathing child? Does he look like a male?, feel carefully with warm hands, if not in scrotum can you feel them elsewhere ie along inguinal tract, ectopic sites or intra abdominal. May need repeated physical examinations especially if retractile testes suspected. If unable to feel then do ultrasound to look for testes. If ectopic/undecended then needs referral to Urologist or Paed surgeon early

 

 

c) Describe methods you could use to ascertain the blood pressure of a 12-month-old

infant.

BP measurement is difficult. Give description of these methods

            Variety of methods

            Flush method

            BP cuff of suitable size (2/3 of upper arm circum.) palpation only or auscultation

            Doppler

 

 

d) A boy who completed treatment for acute lymphoblastic leukemia one year ago,

arrives at your local clinic for a routine follow-up visit. In evaluating this boy for

relapse, what would be important to evaluate on history and examination, and

through routine blood tests?

Thus a good history about CNS symptoms, testes symptoms and those related to marrow relapse. They need to examine the testes in all boys because they may relapse there. They need to look for clinical signs of relapse such as anaemia, purpura, hepatosplenomegaly and lymphadenopathy, bone pain, limps as these would go with marrow or local relapses. Ask re CNS symptoms and signs and if indicated then examine fully to exclude a CNS relapse. A FBC is needed to look for early abnormalities on the FBC as there may be no clinical findings. LFT’s to look for LDH which is a non specific tumour marker and may indicate relapse. They also ned to remember that any other unexplained clinical symptom or sign maybe from the presenting site of relapse,(proptosis, blindness, convulsions etc)

 

Q5

ETHICS

1 mark for each principle, 1 for a definition/explanation

Beneficence
Non-malificence
Patient Autonomy
Justice (Equity)

2 marks for explaining how to use them

FEMALE LITERACY

The mother obtains better standing/more power in the household (from the grandmother) with regard to decisions re: nutrition and child rearing.                                                       (3)


Health Care Workers understand the mother better and communicate better with her; accords her more respect            (3)


Mother has improved ability to understand health education in relation to children and act on it.                                                     (2)


Pertinent examples                                                                             (2)


Mistakes:

Medicines and labels  - very difficult to understand

Literacy ≠ tertiary education. 

Literacy does not automatically create jobs.

 

ANTIBIOTICS FOR GE:

Yes - should not be given                                                                               (1)

Most caused by viruses                                                                                  (1)

Antibiotics kill natural gut flora which is protective                 (1)


Exceptions:

  1. Neonates – GE may be a manifestation of sepsis                                         (2)
  2. Kwashiorkor and marasmic kwashiorkor - prophylactic AB’s 

given due to poor nutritional status and possibly poor

immunological response                                                                                 (2)

  1. Dysentery – appropriate antibiotics/antiparacytic therapy

depending on cause                                                                                        (1)

  1. Where stool culture identifies a causative organism. 

      Even here - caution in some cases, eg. S.typhi species,       antibiotics can cause prolonged diarrhoea           (1)

 

  1. Bowel cocktail including oral, non-absorbed antibiotics used

but only for prolonged diarrhoea                                                                     (1)

 

Where the student shows a propensity for using AB’s inappropriately, marks are deducted.  Many candidates are “trigger-happy” – seeking an excuse to give AB’s, rather than treat according guidelines.


POLIO ERADICATION:

Reduction vs eradication                                        (2)

Polio immunisation TOPV – Part of EPI        (3)

Also Immunisation campaigns                                    (1)

AFP surveillance                                                         (2)

Importation of polio from neighbouring states            (2)

 

P2:Q1:

Sipho, a 5-year-old boy known to be HIV infected and with WHO clinical Stage 3 disease, is brought to you in the outpatient department with a three-day history of cough and difficulty breathing, and fever. He is not on antiretroviral therapy, and was last seen at the HIV Clinic two weeks ago when CD4 test was done. The results are not yet available. An aunt who lives in Sipho’s home has been on TB treatment (from before she moved into the house four months ago).

You find that Sipho weighs 15.2kg (10th centile), has a temperature of 39°C, generalised adenopathy and hepatosplenomegaly. His respiratory rate is 60 breaths/minute, there is alar flaring and some intercostal recession. There is decreased movement of the right chest, which is also dull to percussion and has diminished breath sounds.

 

  1. List THREE underlying pathologies that could account for the chest signs that you found.                                                                                                                                  (3)

 

Collapse/consolidation

Pleural effusion

Chronic lung disease with fibrosis on the right

 

  1. What are the THREE most likely pathogens that may cause Sipho’s possible chest pathology?                                                                                                                          (3)

Strep pneumoniae

Staph aureus

Mycobacterium tuberculosis

 

  1. List FOUR investigations (other than a chest X-ray) that you would consider doing and offer a reason for undertaking each test.                                                           (4)

 

Bacterial infection:

WCC

Blood Culture

Tuberculosis:

Skin test

Sputum AFB’s (saline neb induced)

 

A Chest x-ray reveals a “white-out” of the right chest.

 

  1. What are the two most common pathologies causing a “white-out” on a chest X-ray?                                                                                                                                     (2)

 

  • Pleural fluid
  • Collapse/consolidation

 

  1. List FOUR ways how you would distinguish between these two conditions clinically.                                                                                                                                (4)

 

Collapse consolidation

Pleural Fluid

Percussion

Dull

Stony dull

Auscultation

Bronchial breathing

Diminished breath sounds (bronchial breathing at fluid level)

CXR: lung markings

To lung periphery

No lung markings

CXR: lateral decubitis

No fluid level

Fluid level

Ultrasound chest

No fluid

Fluid +/- strands and debris
  1. If the findings suggest fluid in the right pleural space, describe your immediate management.                                                                                                             (3)

 

  • Main concern is empyaema because of pyrexia, and signs of “toxicity”
  • Needs intravenous antibiotics to cover pneumococcus, staphylococcus and gram negatives (penicillin, cloxacillin, aminoglycoside)
  • Chest drain is mandatory

 

  1. List the investigations you would request on fluid obtained from the pleural space.                                                                                                                                (4)

 

  • Urgent gram stain
  • WCC and differential
  • Bacterial culture and sensitivity
  • AFB M,C&S
  • Total protein and glucose

 

  1. What are the complications of fluid in the pleural space, and how should they be managed?                                                                                                                         (5)

 

  • Mechanical: large effusion compromises ventilation and needs drainage
  • Infection-related:

Septicaemia/disemminated infection: antibiotics, empyaema drainage

Empyaema may loculate: thoracic surgery

 

  1. Briefly outline how you will manage Sipho’s:

a)     Exposure to his aunt with TB                                                                             (4)

 

  • Find out about aunt (TB type, MDR, on treatment, duration etc)
  • Sputum for AFB’s
  • Skin test
  • If CXR has military pattern suggestive of disseminated TB, needs lumbar puncture
  • Classify TB: contact, suspected, confirmed, pulmonary, extra-pulmonary, meningitis
  • Treat according to classification

 

b)     HIV infection                                                                                                       (4)

 

  • Check HIV history and test result
  • Review and revise clinical stage
  • Get CD4 result (noting that as stage 3, he already qualifies for HAART)
  • Initiate antiretroviral programme: find defacto caregiver, identify ART site, refer for adherence counselling

 

c)     Nutritional status                                                                                                 (2)

 

  • Review growth trend for faltering or fall off
  • Initiate in-hospital nutritional support (micro and macro nutrients)
  • Plan for nutritional support once discharged

 

d)     Access to social support services                                                                  (2)

 

  • Assess eligibility for social grants (child support, foster care)
  • If eligible, refer appropriately

 

 

Q2:

 

Thabo is an 8-week-old male. He is brought to the paediatric out-patient department

because of nasal congestion and a mild cough. Thabo is being breastfed without problems and is growing well. Thabo’s pulse is 130 per minute, respiratory rate 30 breaths per min, blood pressure 80/60 mmHg and he is apyrexial. He is noted to have purplish lips, hands and feet. Auscultation reveals a loud and single S2; a grade 3/6 ejection systolic murmur heard loudest at the mid and upper left sternal border. There are no other murmurs or thrills. The liver is felt 1 cm below the right costal margin and is soft. The peripheral pulses are of equal intensity in the upper and lower extremities. Capillary refill time is less than 2 seconds. The pulse oximeter saturation is 68% and a hyperoxia test shows an increase in the oximeter saturation to 70%.

 

a) Interpret the significance of each of the following:

i) Vital signs. (2)

ii) Purplish lips, hands and feet. (1)

iii) Murmur. (2)

iv) 1 cm liver. (1)

v) Oximeter saturations. (1)

 

a)      Vital signs – within normal range for age (no danger signs)

b)      Indicates central cyanosis, most likely due to Rt to Lt shunt

c)      The second heart sound is single because one does not hear the pulmonary component in the setting of less-mobile pulmonary valve

d)      3/6 systolic ejection murmur indicates RVOT obstruction (infundibular and/or pulmonary  stenosis)

e)      Liver normal size (no congestion)

f)       Pulse oximetry low, may indicate cyanotic heart disease with right to left shunting.

b) What is the hyperoxia test, and explain its relevance in this scenario? (3)

The hyperoxia test is a screening diagnostic test used to determine if the cyanosis is caused by the circulatory or pulmonary systems. The infant is placed in room air and the saturation measured. The infant is then placed in 100% oxygen environment and the saturation is again measured. If the problem is in the lungs, the saturation should increase with supplemental oxygen. If the problem is caused by cardiac disease, the saturation should not improve with the supplemental oxygen. This is because there is still mixing of saturated and desaturated blood in the heart.

 

 

c)      What is your hypothesis (diagnosis) at this stage? Explain. (5)

Congenital heart disease  presenting with cyanosis:

  • Right-to-left shunting

 Tricuspid atresia,

 Pulmonary atresia

Critical pulmonary stenosis

Tetralogy of Fallot

  • Common mixing

Total anomalous pulmonary venous drainage

Truncus arteriosus

Double inlet ventricle

Double outlet ventricle

  • Transposition of the great arteries with VSD/PDA

 

 

A chest radiograph is requested. It shows clear lung fields, no cardiomegaly and a

boot-shaped heart. The electrocardiogram shows upright T waves in V1 and V2 and

evidence of mild right ventricular hypertrophy.

 

 

d) What is the most likely diagnosis now? Explain. (3)

Tetralogy of Fallot

Typical clinical and radiological findings and RVH on ECG.

 

 

 

 

e) List THREE chest radiographic signs usually associated with a boot-shaped

heart? (3)

The heart size is normal or smaller than normal

Pulmonary vascular markings are decreased

A concave main pulmonary artery segment

Right atrial enlargement (25%)

Right aortic arch (25%)

 

 

 

f) List THREE ECG criteria for the diagnosis of right ventricular hypertrophy in

a child. (3)

Right axis deviation for the patient’s age

Pure R wave > 12 mm in V1

Upright T wave V1

Q wave in V1

 

 

 

g) What additional investigation(s) would you consider doing and why? (2)

Echocardiographic findings are diagnostic in infants and young children, and echocardiography may be the only examination required prior to surgery.

 

If in doubt after echocardiography, perform cardiac catheterization.

Cardiac catheterisation will help a) to assess pulmonary annulus size and pulmonary arteries, b) to assess the severity of RVOT obstruction, c) to locate the position and size of the VSD, d) to rule out possible coronary artery anomalies.

 

g)      How will you manage Thabo now and in the future? (10)

Medical

·         Recognize and treat hypoxic spell: Hypercyanotic episodes are characterized by paroxysms of hyperpnea, prolonged crying, intense cyanosis, and decreased intensity of the murmur of pulmonic stenosis. Treatment include oxygen, knee/chest position, morphine, intravenous fluids, sodium bicarbonate, propranolol (beta-blocker), or increasing systemic vascular resistance by administration of drugs, such as phenylephrine.

·         Oral propranolol to prevent hypoxic spells while waiting for corrective surgery

·         Relative iron-deficiency anaemia should be detected and treated

·         Good dental hygiene

·         Prophylaxis against IE

·         Monitor growth

Surgical

Correction of tetralogy of Fallot at younger age does not increase morbidity or mortality and has potential advantages and therefore is the treatment of choice.

·         Symptomatic infants – any time

·         Asymptomatic and minimally cyanotic: 3 -24 months of age

·         Asymptomatic and acyanotic “pink tet”: 12-24 months of age

A patient with unfavourable anatomy  may require a palliative procedure before total correction.

Long-term follow-up every 6 to 12 months

Watch for arrhythmias (Holter monitor, pacemaker therapy)

IE prophylaxis throughout life

 

 

h) List FOUR long-term complication(s) that Thabo may be at risk for? (4)

 

Complications before operation

  • Polycythaemia   
  • Brain abscess
  • Infective endocarditis
  • Pulmonary and/or cerebrovascular thrombosis

Postoperative complications

·         Congestive heart failure, residual outflow obstruction, VSD,  and/or pulmonic regurgitation

·         Atrial flutter, ventricular arrhythmias and possible sudden death, right bundle-branch block.

·         Infective  endocarditis

 

Q3:

 

Judy, a 6-year-old girl, presents with a one-week history of malaise and anorexia. She

appears alert but has some periorbital oedema and her blood pressure is 150/80. She also has evidence of infected scabies.

 

a) List TWO important questions that you will ask Judy or her caregiver? (2)

a)        – Is Judy passing any urine?

-  What colour is the urine? Is there any blood in the urine?

- does she have a headache, vomiting, or visual disturbance?

- has she had seizures?

b) List THREE important signs you will specifically look for/evaluate, other than

those described in the scenario? (3)

b)        –Signs CCF- dyspnoea, cough, tachypnoea, cardiomegaly displaced apex , gallop

        -Pulmonary venous congestion: bi-basal crackles, wheeze, cyanosis

- Systemic venous congestion: Tender congested hepatomegaly, raised JVP,            periorbital, pedal or sacral oedema, abnormal weight gain.

- Papilloedema and other hypertensive retinal changes

 

c)        What bedside test would you perform? What is the result likely to be? (3)

Urine examination: grossly urine typically smoky coke coloured and dipstick testing would typically show 3 to 4+ haematuria, proteinuria commonly present but usually less than 3+, acidotic pH, and concentrated (increased specific gravity).

 

 

d) What is the most likely diagnosis? . (2)

d)        Acute post streptococcal glomerulonephritis (APSGN) with hypertension,

Complicating Streptococcal impetiginised scabies

 

e) Interpret and explain the aetiology of the blood pressure reading? (3)

A blood pressure measurement of 150/ 80 is abnormally high for a 6 year- The measurement should be made with an appropriately sized cuff i.e. the cuff should cover at least 2/3rds of the upper arm and taken with the child in a calm state.

·         The aetiology of the hypertension multifactorial: Immune complex deposition in the glomeruli

·         Glomerular inflammation     reduced GFR with water retention

·         oliguria

·             increased tubular absorption of salt and water (retention)

·         Increased extracellular fluid(ECF) volume and oedema

·         Plasma rennin levels may be increased despite expanded ECF

Immune activation of cytokines with pressor effects.

 

f) List THREE further investigations that are likely to be useful, and what would

the results be if your provisional diagnosis is correct? (3)

·         Clean voided urine specimen to the laboratory for microscopy and culture:

Dysmorphic red blood cells

Red cell casts

Granular casts

Culture usually sterile

·         Evidence of streptococcal infection

o        Pus swab from the skin(streptococcal infection)

o        Anti-DNase B levels raised

o        ASOT titres raised

·         Haemolytic complement components C3 and C4 are depressed but should normalise within 6 to 8 weeks.

·         Renal function is impaired with elevated serum urea and creatinine concentrations. Hyperkalaemia and metabolic acidosis reflect the severity of the renal impairment.

·         Chest radiographs often show cardiomegaly with perihilar central venous congestion.

 

 

g)        Explain the pathophysiology of this condition. (6)

·         Immune mediated

·         Nephritogenic strains of Group A beta haemolytic streptococci associated with throat and skin infections

·         Following infection latent period of 7-10 days

·         Immune complexes localise on the Glomerular capillary walls, complement cascade activation> inflammatory response > characteristic histological picture of swollen Glomerular tufts, mesangial proliferation, granular deposition of IgG and C3

·         Pharyngitis-related acute PSGN leads to increased ASOT

·         Impetigo-related APSGN leads to raised anti-DNase levels

·         >typical clinical picture of oedema, haematuria and hypertension

·         Resolution of the inflammatory response and return to normal over the next couple of weeks.

·          

 

h) How will you manage the

i) Oedema. (2)

ii) Hypertension. (2)

iii) Scabies. (2)

h)      (i) Oedema management:

            If significant, bed rest in the first few days

            Salt and fluid restriction in the acute phase to replace insensible losses initially to  minimise vascular overload and hypertension.

            Loop diuretics improve and increase urinary output and reduce length of    hospitalisation.

 

     (ii) Hypertension management:

            Mild – diuretics often help reduce the increased extracellular fluid volume.

            Moderate – calcium channel blockers e.g. Amlodipine, Nifedipine

            Severe – controlled reduction with IV infusions Labetalol, Hydrallazine,       Nitroprusside.

 

     (iii) Scabies management             

·         The skin lotion (usually Benzyl benzoate) applied from the head area to the bottom of the feet. It is left on for 10-14 hours and then washed off in the shower. It is        best to apply at bedtime and then wash off in the morning. This treatment is often repeated days 2 and 3. Younger children use 5% Sulphur ointment. Failure may occur and there are other agents.

·         The itch should be treated with antihistamines.

·         The intense inflammatory response may require treatment with topical steroids

·         Keep nails clean and short.

·         The clothing, towels and bed clothes hot cycle wash and iron/or hot drier.

·         The family: Important to treat index case and household contacts regardless of symptoms simultaneously to avoid reinfection. If a child with scabies attends daycare or is institutionalized, then staff in contact with the person as well as others should be treated.            

·         Treat secondary infection with Penicillin V K / erythromycin if penicillin allergic

 

i) What other monitoring and management steps will you institute? (4)

General nursing orders:

                        Bed rest

                        Daily weight

                        Daily urine dipstick

                        Controlled fluid intake with initial restriction

                        Fluid input and output documentation

                        Low salt, normal protein, high energy diet

                        Blood pressure measurement 3hourly (include when to alert doctor)

            Specific:

                        As above see answer (h).

                        Add infection (antigen) elimination with oral Penicillin x 10 days. Consider                          treating close household contacts

                        Consultation with the renal team if atypical features

 

j) What should Judy’s parents be told about her immediate and long-term

prognosis? (5)

·         Explanation of the condition, its complications in their child and management - their daughter does not show any serious complications

·         Relevance of infected scabies/ associated throat infections and early treatment

·         Emphasise temporary renal damage/impairment

·         Emphasise resolution and healing complete, resolution of oedema and hypertension

·         Frank haematuria will disappear in 1-2 weeks, dipstick haematuria slower to resolve

·         Kidneys will be normal( vast majority)

 

k) What are the public health implications of this condition? (3)

·         Death rate extremely low, prevention being the main thrust

·         Overcrowding favours the spread of both scabies and streptococcal infections

·         Both infections/infestations are able to reach epidemic proportions although often clustered

·         Importance of early treatment of family members and close personal contacts as well as index case

·         Hospitalisation of cases to control BP, severe oedema and renal impairment

·         Prognosis in children very good but a proportion of adults with the same genetic predisposition contracting the condition may go onto chronic renal failure, further straining resource limited Health services

 

 

 

 

 

 

 

 

 

 

Q4

a. Optimal Site:                                                                                                           (8)

Underserved area

Lots of patients

Far from other clinics/mobile points

Consider current mobile clinic visiting point for the new fixed clinic

Permission from (negotiating with) local community

Acceptable road (may be dirt or tar)

Electricity – almost essential, otherwise generator

Water - essential

Sewage – could be pit latrine

 

 

 

                                                                                   

b. Services:                                                                                                           (10)

 

ANC

Deliveries.   Must be considered whether you decide for or against.

Rapid HIV and PMTCT

Contraception

Maternal education, Post natal care

 

Immunization

Food supplementation

RTHC + GOBIFFF

Contraception

Well baby services

Nutrition:  Growth monitoring.  Food supplementation

 

c. Staffing:                                                                                                                  (8)

 

No permanent doctor, but doctor to make weekly/monthly/2x month visit

1 qualified Sister/Senior Professional Nurse.

Maternity and/or IMCI training. 

2-3 more Staff Nurses/Nursing Assistants

Cleaner – part-time

? CHW/ Lay counsellors

Better if they are based in the community serviced by them

 

 

d. Training:                                                                                                                (6)

 

IMCI trained                                                   

Primary Health Care training

Midwifery trained

Pre-training

Monthly Continuing Education at hospital

In-service training as required

 

 

e. Drug Supply:                                                                                                           (8)

 

EDL Drugs

According to demand/requirements

Orders - regularly 1x/week or 2x/month

              as transport/ambulance is available

Supplied from the hospital pharmacy.

Nurse control: Fridges – one specifically for medicines only

Lockable cupboards

 

Question was drug supply – not list of drugs.

 

 

Q5:

 

Ntombenhle is a 13 month old girl. Her mother brings her to the local clinic. Ntombenhle has had a cough for two days and noisy breathing for the past day. Her Road to Health card shows that she only received her 6 and 10 week immunisations and none since. Ntombenhle is calm and does not appear “toxic”. The clinic nurse notices that Ntombenhle has a barking cough, a hoarse voice and stridor. She counts Ntombenhle’s respiratory rate - 39 breaths per minute - and takes her temperature which is 37.5°C. The nurse nebulises Ntombenhle while she sits on her mother’s lap and then arranges for an ambulance to transfer Ntombenhle and her mother to the nearest hospital.

 

1. Is the nurse’s decision to refer Ntombenhle to the hospital appropriate based on her IMCI classification? Explain.                                                                                                (2)

 

Yes. Stridor in a calm child is a red classification – refer urgently to hospital.

 

2. What is the most likely diagnosis?                                                                          (2)

Laryngotracheobronchitis / Croup

 

3. List THREE other possible differential diagnoses, and briefly indicate why each is unlikely.                                                                                                                               (3)

Epiglottitis – too young, low temp, not toxic, not drooling

Tracheitis – not toxic, no erythematous rash

Foreign body aspiration – three day history (not sudden)

Severe oral thrush

Accept others, if relevant

ANY CAUSE FOR CHRONIC STRIDOR INCORRECT

 

4. What drug would the clinic nurse have administered to Ntombenhle using the nebuliser?  (1)

 

Adrenaline or corticosteroids

 

5. Explain the mechanism of action of this drug in a child with stridor.                     (2)

 

Reduces inflammation (airway narrowing), promotes vasoconstriction allowing airway to open (less swelling).

Wrong- bronchodilatation

 

 

You are the attending doctor when Ntombenhle arrives at the hospital. You find her to be restless. She is pink in nasal prongs oxygen, has a respiratory rate of 47 breaths per minute, and has inspiratory and expiratory stridor. Her blood pressure is 100/70mmHg and she has a palpable pulsus paradoxus.

 

6. How would you grade the stridor? Explain                                                                         (2)

 

Grade III: Inspiratory and Expiratory Stridor and Pulsus Paradoxus.  

 

7. Describe how you would identify a palpable pulsus paradoxus?                           (2)

 

Pulse becomes weak or disappears with inspiration. Use only a light touch to feel pulse

 

8. List THREE organisms that may responsible for Ntombenhle’s condition.           (3)

 

Parainfluenza Virus, Influenza Virus, Herpes, Measles, Adenovirus, H. Influenza B, Diphtheria, Strep. pneumonia, Staph. aureus

 

9. How will you manage Ntombenhle in hospital?                                                      (4)

 

Keep child happy- parent should stay with child.

Avoid procedures that may evoke crying – e.g. bloods, suctioning, physio

Regular adrenaline nebs every 20-30 mins until stridor resolves

Steroids : prednisone 2 mg/kg or parenteral dexamethasone (Decadron) 0.6 mg /kg

(Antibiotics not indicated- no marks)

 

10.              There was disagreement among staff about whether Ntombenhle should be provided with humidification when she arrived at the paediatric casualty unit.  An evidence-base search yields the following abstract.

 

Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: a randomized controlled trial.

Scolnik D, Coates AL, Stephens D, Da Silva Z, Lavine E, Schuh S.

Division of Pediatric Emergency Medicine, The Hospital for Sick Children, and University of Toronto, Toronto, Ontario.

CONTEXT: Children with croup are often treated with humidity even though this is not scientifically based, consumes time, and can be harmful. Although humidity using the traditional blow-by technique is similar to room air and no water droplets reach the nasopharynx, particles sized for laryngeal deposition (5-10 microm) could be beneficial.

OBJECTIVE: To determine whether a significant difference in the clinical Westley croup score exists in children with moderate to severe croup who were admitted to the emergency department and who received either 100% humidity or 40% humidity via nebulizer, or blow-by humidity.

DESIGN AND SETTING: A randomized, single-blind, controlled trial conducted between 2001 and 2004 in a tertiary care pediatric emergency department.

PARTICIPANTS: A convenience sample of 140 previously healthy children 3 months to 10 years of age with Westley croup score of more than 1 or 2 or higher (scoring system range, 0-17); 21 families refused participation.

INTERVENTION: Thirty-minute administration of humidity using traditional blow-by technique (commonly used placebo, n = 48), controlled delivery of 40% humidity (optimally delivered placebo, n = 46), or 100% humidity (n = 46) with water particles of mass median diameter 6.21 microm.

MAIN OUTCOME MEASURE: A priori defined change in the Westley croup score from baseline to 30 and 60 minutes in the 3 groups.

RESULTS: Groups were comparable before treatment. At 30 minutes the difference in the improvement in the croup score between the blow-by and low-humidity groups was 0.03 (95% confidence interval [95%CI], -0.72 to 0.66), between low- and high-humidity groups, 0.16 (95% CI, - 0.86 to 0.53), and between blow-by and high-humidity groups, 0.19 (95% CI, -0.87 to 0.49). Results were similar at 60 minutes.

a)      What type of study design was used? (1)

Randomised controlled trial

 

b)      What is meant by “single-blind” trial? (1)

Either the study participants or the doctors (one of the two) did not know which treatment arm was being offered to whom.

 

c)      What is meant by “convenience sampling” How valid a sampling strategy is this? (2)

Researchers choose the next participant in the study (when it is convenient) rather than this being an automatic (random) event as defined by the study entry criteria.

Poorest form of sampling – can exclude patients one does not “like”.

 

d)      What was the measure used in this study to decide which therapy worked best?(1)

The Westley croup score.

 

e)      Explain and interpret what the 95% confidence interval means in the statement “At 30 minutes the difference in the improvement in the croup score…. between low-and high humidity groups was 0.16 (95% CI, -0.86 to 0.53)”? (2)

If the study was repeated a 100 times, in 95% of instances the change in the croup score would range from a negative effect (-0.86) to a positive effect (0.53). This means the effect could go either way if the study was repeated (although it was a +0.16 in this study).

 

f)       Was there a statistically significant difference in outcome between the between the low- and high-humidity groups at 30 minutes? Explain. (2)

No, the 95% CIs of the difference in improvement (0.16) includes 0 (point of no difference)

 

g)      Based on the study findings, would you offer humidification to Ntombenhle? (2)

No, the study does not support the use of humidity for children with moderate to severe croup treated in the emergency department.

11. List TWO signs that may indicate that Ntombenhle’s condition is worsening.     (2)

 

Marked retractions, restlessness, confusion, cyanosis, falling oximeter sats, increasing tachycardia, stridor becoming less prominent, apnoea

 

12. How would you manage Ntombenhle if her condition worsened further?           (2)

 

Transfer to ICU

Intubate nasotracheally (or perform a tracheostomy)

.

 

Despite appropriate treatment, Ntombenhle continues to deteriorate. You contact your referral centre which has ventilation facilities. A rapid HIV is done on Ntombenhle which is positive. The referral centre refuses Ntombenhle admission to the ICU because of her positive HIV test.   

 

13. Is the decision by the ICU to deny Ntombenhle access justifiable? Briefly discuss. (4)

 

No.

Rapid HIV on child only proves that child HIV exposed (may still be maternal antibodies).

Has an imminently reversible condition (short-stay in ICU required).

Good outcome even if HIV positive.

 

14. Explain how you will arrange Ntombenhle’s “catch-up” immunisation.               (2)

Get all outstanding vaccines today- polio, DTP, Hib, Hep B (14 week dose) and measles (9 month dose)

Next immunisations at 18 months (routine visit)

HIV exposed status does not affect immunisation delivery.

 

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