Microsoft word - dch oct 2012 p2.docx

DCH SEPT/OCT 2012
P2; Q1:
Dog bite management
1.
Management of the wound or scratch: Wash the lesion with soap and water and apply povodine cream which has been proven to be having an antiviral activity. 2. Look for a dog Rabies vaccination certificate. If present and the dog has been vaccinated within 3 yrs then the management stops there. If there is no proof of vaccination then the WHO RECOMMANDATION should be followed. a. Vaccine 0.1ml should be given intra dermally on 2 deltoids on day 0,3,7and 28(Red Cross) or another regime(Oxford) which consist of 8 injections each upper arm, each lateral thigh, each supra scapular region ad each on the lower quadrant region of the abdomen on day0 and day 7 , 4 injections 1 each on both upper arms and1 each on lateral thighs. And repeat day 7 regime on day 30 and 90. 4. Give Rabies immunoglobulin around the bite area on day 0.
Childhood Enuresis
Enuresis is diagnosed when a child still wet a bed or clothes at an age where he or
she is supposed to be dry and that age is 5 years of age .
Divided into primary and secondary.
Primary – This is a child that has never been dry . The common cause is bladder
immaturity that is charecterised by small capacity. Delayed maturity of the AVP
receptors has also been mentioned as a cause.
Secondary enuresis is charecterised by history of dryness that is then followed by
bed wetting. Then is usual y some underlying pathology and these may be :
a. Constipation
b.
Congenital abnormalities of the urinary tract. Rewards- Chart dry days and reward dry nights . Assure the child that there The child should be encouraged to void before sleeping and fluid drinking at There should be no humiliation nor punishment for the child. Consistent bed training and reinforcement has 80 % success.
Psychotherapy may be needed for the children under stress.
Medical management involves the use of DDAVP and the success rate is low in that
the patients relapse after stopping the treatment and the patients should be
monitored for convulsions because of hypervolaemia.

Acute flaccid paralysis
Usually LMNL with intact cognitive function
Main clinical features: areflexia, hypotonia and weakness
Infectious
 GBS: ascending paralysis, post infectious. Recovery reverse, albumino- cytological dissociation: Rx- IVIG, plasma exchange  Variants: axonal type, CIDP: Rx steroids  Acute infectious polymyositis: high CPK tender muscles: RX steroids  Enterovirus: polio- asymmetric, coxsackie, echovirus, prodrome, pain, aseptic meningitis: Rx acyclovir – mainly supportive NMJ
 Myasthenia crisis: fatigability, normal NCV: Rx pyridostigmine, IVIG
 Organophosphate poisoning: bronchorrhoea, miosis, arrhythmia, fasciculations: Rx- atropine, obidoxime, decontamination  Neuromuscular blockade: ICU- nondepolarising agents  Botulism: dysarthria, bulbar signs, weakness – descending: supportive High IV steroids  Tick paralysis: GBS picture with CN involvement Channelopathies/electrolyte
 Severe hypoK/Ca/Mg – GE – correct iv fluids/replacement
 CHO meal induced paralysis, facial sparing Rx carbonic anhydrase inhibitor Andersen syndrome: dysmorphic, prolonged QT syndrome –oral KCL Management: depends on cause Mainly supportive: airway, haemodynamic stability, may require IPPV The diagnosis of infective endocarditis.
Infective endocarditis must always be suspected clinically if the patient has a cardiac
lesion therefore murmur, anaemia and fever. The definitive diagnoses is made using
Revised Dukes criteria and is as follows :
Revised Duke Clinical Diagnostic Criteria for Infective Endocarditis
Major criteria
Two positive blood cultures for organisms typical of endocarditis Three positive blood cultures for organisms consistent with endocarditis Echocardiographic evidence of endocardial involvement:  Oscillating intracardiac mass on a heart valve, on supporting structures, in the path of regurgitant jets, or on implanted material without another Mnior criteria
Microbiologic evidence of infection consistent with but not meeting major criteria Serologic evidence of infection with organisms consistent with endocarditis For definite clinical diagnosis: 2 major criteria or 1 major and 3 minor criteria, For possible clinical diagnosis: 1 major criterion and 1 minor criterion or 3 For rejection of diagnosis: Firm alternative diagnosis explaining the findings of infective endocarditis, resolution of symptoms and signs after antimicrobial therapy for ≤ 4 days, no pathologic evidence of infective endocarditis found during surgery or autopsy, or failure to meet the clinical criteria for possible Adapted from Li JS, Sexton DJ, Mick N, et al: Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clinical Infectious
Recurrent headaches in children.
Headaches are common in children and if they are recurrent they indicate the
underlying problem. The most common cause of recurrent headaches in children are:
1. Raised intracranial pressure: - as result of either brain tumours or CSF flow 2. Migraine 3. Psychogenic factors or stress 4. Refractory errors and strabismus 5. Sinusitis – mostly due to atopy 6. Malocclusion of teeth Infants and children respond to headaches in an unpredictable fashion. Toddlers – irritability and crankiness. May vomit and become photophobic and rub their eyes and head. Older children will be able to report headaches Clinically one must exclude the above mention causes and investigation depend on clinical examination as CT scans, MRI, allergy testing and eye testing may be requested. Management depends on what is diagnosed
For migraine needs the American academy of neurology guidelines. Paracetamol in
combination with Ibubrofen may be used. With intractable migraine Triptans are
better drugs.

P2; Q2:

Write short notes on:
a. Factors affecting the poor uptake of vaccines in South Africa
Possible Reasons could include the following, but other reasonable responses will also be given credit. A minimum of 5 factors mentioned and explaining their relevance would suffice, or listing 10 factors would also suffice. Poor maternal education and knowledge regarding vaccinations Failure of primary care clinic logistics eg running out of stocks etc Migrant populations eg refugees, asylum seekers Ethnic beliefs, particularly in rural communities Lack of networks amongst mothers ie learning from others
b. Hypertonic
dehydration
Candidates should at least DEFINE what is meant by “hypertonic dehydration”, discuss situation in which this commonly occurs; A brief discussion of the patho-physiology of hypertonic dehydration, its clinical presentation and complications, and the acute management Define what hypertonic dehydration is – refers to dehydration with serum sodium >150mmol/L, or hypernatraemic dehydration. Excess water loss eg acute gastro-enteritis, diabetic keto-acidosis, premature neonates Patho-physiology is that of excess water loss compared with loss of electrolytes. There is loss of water from the intracellular space into the extracellular space, and thus shrinkage of the cells especially in the brain with resultant production of compensatory intra-cytoplasmic idiogenic osmols. Clinically patients may not appear dehydrated, the skin has a “doughy” texture, and patients are often irritable with high pitched cries, hypertonia and brisk Rapid rehydration especially using hypo-osmolar fluids may lead to cel ular swelling and oedema. More devastating complications of cerebral vein thrombosis or bleeding can occur. Fluids recommended to be used must be as isotonic as possible: use 0,45% dextrose saline or 0,9% dextrose saline as slow rehydration over 48 hours Lowering serum sodium should not exceed >0,5mmol/L/hour over 48 hours c. Prevention of Childhood drowning
Candidates should have a broad approach with respect to prevention of illness or injury, with emphasis on PRIMARY, SECONDARY and TERTIARY preventative factors. Supervision A child should never be left alone or with another child near body of water Constant adult supervision and closely watching – especially social gatherings; Adults take turns to be “lifeguards”; Adults should not be under influence of alcohol or drugs at time; Adults should also be able to “swim” or be watersafe Buckets and baths must be left empty when not in use Fence the pool – should be at least 1,2 meters tall, no gaps wider than 10cm between slats in fence to prevent children squeezing through, self closing and self latching locks beyond childs’ reach; , Teach children to swim – do not rely on flotation aids Remove toys from pools or water to prevent children trying to reach for them Beware of drains and drain covers near pools, spa’s – strong suction may trap clothes or body parts Discourage children from diving or jumping into bodies of water where there is danger of injury due to other hazards Ban the use of drugs, alcohol etc around water, especially for adolescents Learn CPR, updating regularly Have a mobile phone with you at all times – with emergency number d. Using Mortality Data to improve the health of Children
Candidate needs to give some examples on what epidemiologic mortality data is utilized wrt. Monitoring Child health. Examples will include:- Neonatal mortality rate Infant mortality rate Post-neonatal mortality rate Peri-natal mortality rate Child death rate Cause specific mortality rate Case fatality rate ChIP database or Child healthcare Problem identification Programme How epidemiologic data may help in child healthcare eg ChIP data factors as examples may include :- Identify ‘modifiable factors” or areas of health systems weakness at all levels that contribute to child mortality eg in the home, in the primary clinics, the hospitals etc Identify causes of death so as to target future policies eg HIV, TB, gastro-enteritis etc May identify maternal obstetric healthcare vulnerabilities Identify factors that affect neonatal and peri-natal care Identify and improve HIV and TB provisional services Improve recognition and management of childhood malnutrition Ensure Universal use of IMCI guidelines at clinic level Empower community caregivers to provide home-care, recognize danger signs of illness Re-iterate the importance of exclusive breast feeding, optimal feeding choices and good nutrition Ensure that all health professionals are competent to identify and manage common childhood conditions Ensure competency in emergency triage and treatment e. The Tuberculin Skin Test
Candidates should briefly describe the test, its components or make-up, how
and where it should be administered; what the immunologic basis for its
action is; where one would use it in the paediatric setting; how one interprets
the result;
The basis of the TST relies on the fact that the immune reaction after
exposure to mycobacterium tuberculosis or BCG, is a Type IV
hypersensitivity reaction; it may take an individual 6 weeks to 3 months to
mount a response to the antigen as evidenced on the TST. (1 MARK)
What is it?
It is the standard method of determining infection or exposure to
Mycobacterium tuberculosis or BCG in children <5 years. Also known as
Mantoux test. It does not indicate the presence or extent of disease. A
negative TST does not exclude infection
What does it consist of? A standard dose of purified protein derivative 0,1ml (2U of PPD-RT23 2TU), which is attenuated Mycobacterium bovis (1 MARK) How is it administered? Intradermal injection to the left extensor surface of the forearm after cleaning of the skin. Using an insulin syringe, the PPD is injected using the bevel of needle facing upwards, almost parallel to the skin; an area of pale elevation of the skin (a wheal or papule) approximately 6-10mm in diameter should result How is it read or interpreted? An area of induration is measured in millimeters at 48-72 hours after administration. The measurement should be done perpendicular to the long axis of the forearm. Interpretation of the TST (in concert with the clinical history and findings, CXR and risk factors) Positive test Immune status Diameter of positive >5mm >10mm test In children < 5 years or HIV positive, with associated suspicious history and CXR changes should be treated as having TB disease In children < 5 years, or HIV positive, or adults with positive TST with no suggestive history or examination, or CXR changes, should receive prophylaxis for 6 months (2 MARKS) Interpreting negative TST’s False negative TST may result from HIV Malignant immunosuppression Steroids and other immunosuppressive drugs Recent severe viral illness eg measles, chickenpox Poor technique TST Disseminated TB Within the 6week to 3 month incubation period after exposure to MTB
P2; Q3:

Write short notes on:
a. Haemorrhagic disease of the newborn

ANSWER
Background & Cause:
There should be some background to the problem e.g.:
Due to Vit. K deficiency & low levels of Vit. K dependant factors. (Liver immaturity
plays a role.)
The Vit. K dependant factors should be mentioned. (A pathway could be
sketched.) i.e. Factors II, VII, IX, X. (+ Protein C & S) should be mentioned.
Factors contributing to its development in neonates: Immature liver, delayed
colonisation of the gut (various factors responsible for this could be listed), poor
placental transfer of Vit. K etc.
MARKS]
Clinical presentation:
GIT bleeding typical, cephalhaematomas, IVHs, bleeding from umbilicus,
injection sites, post circumcisions etc.
Timing of bleeding: 2nd to 7th day usually in infants who have not received Vit. K.
Investigations:
PT & PTT are prolonged. (This must be mentioned.)
Vit. K dependant factors are decreased.
Platelet count normal. Anaemia if severe bleeding etc.
Differentiation from, e.g. Liver disease and Haemophilia may be briefly
mentioned.
Exclude other causes of bleeding.
Special Investigations could be mentioned (e.g. U/S head, but are not the crucial
to make an aetiological diagnosis.)
Prophylaxis:
Vit. K 1mg IM in SA or oral dose 2mg. All infants must received this routinely,
esp. if breastfed (and documented in the notes).
Treatment:
Vit. K1 IV (not IM) given repeatedly. Improvement usually occurs in 24hrs.
FFP should be given for serious bleeding episodes.
Blood transfusion in extreme cases etc.
Supportive

b. Teenage acne vulgaris
(10)
ANSWER
Some logical headed approach such as: causes, presentation, treatment, advice
etc should be presented.

Background:
Most common teenage skin disease: 85% of all teenagers affected. May be
psychologically traumatic if very severe and physical y scarring. Acne is one of
the earliest stages of adrenarche. Etc, etc.
MARK]

Causes:
Altered keratinisation, androgens, bacteria (Propionibacterium acnes), and
abnormal sebum production result in obstruction of pilosebaceous follicles and
inflammation.
Clinical:
“Blackheads” (open comedones) and “whiteheads” (closed comedones), which
are due to obstruction within follicles.
Erythematous papules, pustules, or nodules, which are due to inflammation.
In some patients, scars or cysts may form. May be painful.
Treatment:
Topical retinoids to normalize keratinization.
Topical keratolytics: salicylic acid.
Topical benzoyl peroxidase preparations.
Topical antibiotics: clindamycin, erythromycin.
Systemic antibiotics: doxycycline, tetracycline & minocycline (>8yrs).
Systemic retinoids for severe cystic acne.
Oral contraceptive pill – low dose.
Some discussion on treatment options re extent and severity and the choice of treatment
Advice:
Explain the causes and process. Debunk myths etc. Prepare a plan of
management. If using retinoids, discuss prevention of pregnancy if sexually
active or likely to be. Etc.
c. Parental responses to having a baby with a congenital abnormality (e.g.
cleft lip) and appropriate health care worker responses

ANSWER

Background:
I am looking for a sensible, caring, practical, non-judgmental approach to dealing
with this common problem. The candidates should be aware of the common
emotional responses and the common sequence of emotional events that they
may encounter as health workers dealing with grieving parents.
Practical ways of dealing with these stages should be offered.
N.B.: The answer must deal with both parental responses and health care
workers approach, as stated in the question.
For example, some of the points mentioned below, amongst many others.
Parents:
Varied parental responses are to be expected, dependant on parental personalities, educational levels, support systems and coping mechanisms of the parents as well as their mental health. Typical responses: A sequence has been identified which many parents pass through: At first: Shock or fear regarding the appearance of the infant. “Loss of the perfect infant.” Reality of the problem sets in. The degree of abnormality is important, esp. facial lesions, as to the parental response. Secondly: Denial/disbelief of what has occurred. Repeated explanation may be required at this point. Thirdly: Sadness. Mourning the loss of their hopes and ideals. Later: Anger. Healthcare workers may be the target of the anger and need to be aware of this stage in order to handle it professionally. Finally Acceptance: This may take variable lengths of time. Health Worker Responses: Respectful and sensitive way of revealing the abnormality to the parents. Encourage early contact and bonding with their child. Emphasize the positive aspects of their child. Explain the mechanism of the defect and the limitations and expected outcome/prognosis. Be knowledgeable about the condition. Research the abnormality before discussion in depth details. Beware of giving rigid timelines for outcomes. Have patience. Show empathy. Ensure parents understand what is said to them. Use appropriate language. Show pre and post operative pictures and good outcomes possible when appropriate, esp. with clefting lesions. Show pictures of children later with repaired clefts. Encourage parents to express their fears and concerns. Allow parents to express their thought on why the lesion occurred. Use appropriate facilities – suitable room etc in which to council. Follow-up interviews are important. Resources to give as handouts may be considered. Deal with practical issues like feeding – get dietetic/speech therapy assistance. Plastic surgery referral etc. This is a broad question and may other valid points will be considered when marking. d. The Baby Friendly Hospital Initiative (BFHI)
The BFHI is a global initiative to encourage hospitals to adopt practices that fully protect, promote and support exclusive breastfeeding from birth. The World Health Organization and the United Nations Children’s Fund launched the Baby Friendly Hospital Initiative (in 1991). It also aims to ensure that all maternity facilities, whether free standing or in a hospital, become centers of breastfeeding support. A maternity facility can be designated 'baby-friendly' when it does not accept free or low-cost breast milk substitutes, feeding bottles or teats, and has implemented 10 specific steps to support successful breastfeeding. The “Ten Steps to Successful Breastfeeding” have been accepted as the minimum global criteria for attaining Baby Friendly Hospital status. The process is currently controlled by national breastfeeding authorities, using Global Criteria that can be applied to maternity care in every country. Ten Steps to successful Breastfeeding

Every facility providing maternity services and care for newborns should:

1. Have a written breastfeeding policy that is routinely communicated to all
2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of 4. Help mothers initiate breastfeeding within a half-hour of birth. 5. Show mothers how to maintain lactation even if they are separated from their 6. Give newborns no food or drink other than breastmilk unless medically 7. Practice rooming-in and allow mothers and infants to stay together 24 8. Encourage breastfeeding on demand. 9. Give no artificial teats (also called dummies) to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. [5 MARKS, 1 BONUS MARK Bonus Mark possible if all 10 listed correctly.] For a hospital that is interested in becoming Baby Friendly, current practices are looked at and compared to the recommended 10 steps. A Hospital Staff Appraisal Tool is available and can be used to see if a hospital is ready to become Baby Friendly. When the hospital staff is satisfied that the hospital meets the baby-friendly criteria, a request can be made for an external assessment to be conducted. If the assessors are satisfied that the hospital has met the 10 steps criteria and the staff are familiar with the ten steps and actually implementing them, the hospital will be accredited with Baby Friendly Status. In South Africa, the importance of the BFHI has been recognized by its inclusion in all major nutrition policies including the Integrated Nutrition Policy and the National Breastfeeding Policy for health workers and health facilities. The aim is for all hospitals to become baby friendly in South Africa. e. Childhood grants currently available in South Africa
ANSWER
The three main grants should be mentioned and named correctly. Come
comment should be made to the application process and completion of the
required documentation, close estimate of the amount etc. Inclusion and
Exclusion criteria should be mentioned.

The Care Dependency Grant: (Not all the information below required for
marks.)

Financial support paid to parents or Foster Parents or Primary Care Giver for
children who are dependant, in order to assist with general and medical care
of the child. The definition of a ‘care-dependent’ child means a child between
the age of one and eighteen years who requires and receives permanent
home care due to his severe mental or physical disability.
Inclusion Criteria:
The child must be between 1 and 18 years of age
At least one of the following conditions (physical or mental) must apply: i. The child is severely disabled to such an extent that he/she needs constant care and supervision at home far beyond that normally required in the raising of a child of her/his age. ii. That where a formal assessment of the child has been carried out it has shown by means of Developmental or Intelligence quotient that the child is profoundly or severely {DQ <30 / 30-50} mentally disabled. iii. That the expense of care of the child due to his/her disability incurs extraordinary expenses far beyond those normally incurred in raising a child of her/his age. Exclusions: The child must not be a resident of a state or state aided: i. Psychiatric hospital i . Care and treatment centre The parent/foster parent must not refuse medical treatment needed for the child provided that the treatment is not life threatening. An applicants income cut-off level is applicable Amount: R1140/child. General: See below.
The Child Support Grant: (Not all the information below required for marks.)
A grant to support all primary caregivers in their role of caring for the child.
For children under (18) of age. {Determined by the Minister.} Applicable to
households who receive a very low income. Means test applied.
Must both be SA Citizen & live in SA.
Max of 6 children/caregiver.
Amount: R260/child.
General: See Below.

Foster Care Grant: (Not all the information below required for marks.)
Paid to the Foster Parent of children placed by the courts in terms of the Child
Care Act.
The person receiving the grant is not their parent but may be a relative.
Foster Parent must be resident of SA (Not Necessarily a citizen.)
Paid until 18yrs (21 if still in school) of age or leaves school.
Usually paid for 2yrs. Then reviewed by social worker or child adopted.
Amount: R740/child.
General: See Below:

General: (Not all the information below required for marks.)
Special situations exist for which the child should be considered for a grant
(which is not covered in the above criteria) - an additional written motivation
should be made in these cases.
Only one grant may be held at a time generally (Foster Care and CDG may
be excluded).
The child must be examined in order to make an accurate assessment.
Examine the child fully in order to complete the medical findings.
Documentation required may be mentioned: Identify applicant by identity
document (13 digit ID number new ID Book) and child by the birth certificate
or ID document (13 digit ID number new ID book or computer printed birth
certificate). Ideally this should be done by social security but you must still
convince yourself that the named child and applicant are indeed those
present.
Process of applying/Appeals process may be mentioned.
Means tests apply.

P2; Q4:

Write short notes on:
a. The management of acute severe childhood asthma a. Describe acute exacerbation and make reference to the clinical signs of increasing severity of lower airway obstruction, with status asthmatic named as the most severe form, non-responsive to high dose inhaled B-stimulants, anti-cholinergics, and systemic
corticosteroids. 3 marks for definition and description of condition
b. Highlight life threatening signs like silent chest, cyanosis, inability to lie down, obtundation.3 marks for clinical features, including life-
threatening signs
c. Tailor management according to clinical signs of severity and response, in a stepwise fashion. Give Oxygen always. Monitor
clinically, by pulse oximetry and by ABGs 2 marks for management
principles
d. Know when to refer for ICU: non-responders and those in imminent / actual respiratory failure 2 marks for appropriate referral
b. The laboratory diagnosis of acute bacterial meningitis a. Based predominantly on CSF Chemistry and Microscopy and Culture, but also additional findings on history or examination. 1 mark for
identification of appropriate tests
b. Indicate CSF WCC, neutrophil and lymphocyte counts together with CSF glucose, CSF-glucose ratio, Gram stain and culture, needed. Indicate cut-offs for each. Indicate “pattern” of TBM vs bacterial, fungal viral meningitis 8 marks for discussion of typical abnormalities and
differentiation from other conditions (e.g. 3 for microscopy,
3 for chemistry, 1 for culture)
c. Early bacterial meningitis can present with lymphocytic predominance 1 mark for this insight. 1 mark for highlighting the lack of value in
performing bacterial latex detection tests
d. Mention age specific differences in CSF profile e.g. neonates vs older infants and children. (optional 1 mark) if included in answer
c. The airway management of a child with suspected head injury a. C-Spine protection at scene, until cleared radiologically AND clinically (NB: SCIWORA) 1 mark for highlighting the importance of C-spine
control throughout
b. Clinical assessment of airway patency – 2 marks
c. Jaw thrust vs. Head tilt with Chin lift – 2 marks
d. Role of oral airways and avoidance of nasopharyngeal airway – 1
e. Airway protection (intubation) for GCS < 8 and other conditions i. Orotracheal route of intubation, fear of skull-base fracture ii. Indicate the need for analgesia, sedation, and muscle relaxation for intubation, NOT ketamine (risk of increased Intracranial pressure) iii. Ongoing airway care, suction with analgesia 2 marks
f. Surgical airways – 2 marks
a. Why notifiable: NDoH plan promotional and preventive measures +monitor trends and disease occurrence over time. Provincial DoH:
implement immediate intervention. 2 marks for background
b. A legislated list of conditions with significant public health impact, for compulsory notification to local, provincial, national DoH. Two categories: A for immediate and B for “routine” within 5 days of clinical diagnosis. 1 mark for highlighting importance of immediate
(including telephonic) notification
c. Name examples of A and B 4 marks for examples of notifiable
conditions
d. Describe notification process: Dx – clinical +/- lab confirmation - notify. A immediate telephonic / fax. Prescribed Form submitted within 5
days. B written notification only within 7 days. Deaths due to notifiable
disease, notified twice, as case and death. 3 marks for explanation
of process
e. Indicate MDR & XDR TB as priority notifications within 24 hours a. Review Clinical Characteristics 2 Marks
b. Describe Birth complications 3 Marks
c. Metabolic complications including hypoglycaemia, pathogenesis and
management principles 3 Marks
d. Congenital abnormalites associated 2 Marks

Source: http://www.collegepaeds.ac.za/past%20papers/2012-10/DCH%20OCT%202012%20P2.pdf