Paeds Escrito

4) An anxious mother presents with her 5 day old baby who she has noticed has yellow eyes: a) What 3 additional histories would you like to find out? b) List 3 possible differentials? c) What laboratory investigations would you do to confirm your diagnosis? d) Depending on your diagnosis, how would you manage this patient?

Duration of jaundice?, mother's blood group?, breastfeeding well? any other danger signs? Neonatal jaundice secondary to 1) ? ABO/ Rh incompatibility 2) Neonatal sepsis 3) Galactosaemia Serum bilirubin, FBC, Blood C/S, Baby and mother's blood group and Coombs' test, Depends on cause

2. A5-year-old boy has a 2-week history of nasal congestion and night time cough which has worsened over the past three days. His past medical history is significant for recurrent cough. His younger brother was diagnosed with eczema during infancy. a)Based on the most likely diagnosis, what 3 additional points would you elicit from the history? Briefly indicate their relevance. b) Outline 5 important physical examination findings that might be present: C Outline 2 key principles in the immediate management of this patient: c) List 2 important acute complications of this condition:

family history, known triggers/allergens dust personal history of atopic, breathlessness, chest tightness, expiratory wheezing present: Tachycardia, Tachpnoea, inability to complete full sentence in one breath, silent chest pulsus paradoxus, spo2 <92 Bronchodilation, Anti-inflammatory agents; Oxygen Respiratory failure, pneumothorax, pneumomediastinum, cardiac arrest, hypoxic-ischaemic CNS injury

2. A neonate is noticed to be blue' and is rushed to the neonatal intensive care unit. a) List the types of cyanosis that may be present in newborns: b)Briefly outline how you would differentiate clinically between the types of cyanosis listed in (a): c) Outline 5 important points you would obtain from the history, indicating their relevance: with same presentation d) List 5 important investigations you would consider in a cyanosed newborn:

peripheral and central Limited to extremities vs. affecting mucous membranes and tongue Gestation age at which was born Apgar score History of PROM History of infection Mode of delivery Weight at birth Previous child with same presentation Any 5 relevant eg. random blood sugar, chest x-ray, FBC, ECG, ECHO, arterial blood gases, septic screen etc.

5 A 5 day old boy presents to the emergency room with a bleeding circumcision. a) Outline 4 key points you would obtain from the history, with justification: done under b) List 2 differential diagnoses: bleeding haemophilia; c) List 3 important investigations you would do and indicate their relevance: d) Outline 4 steps in the immediate management of this baby:

-Family history bleeding disorder, -Vit K injection after birth, where was it done and how, was it done under septic condition -Inherited bleeding disorder e.g. haemophilia; - Vitamin K deficiency bleeding in the newborn, -Bleeding vessel from improper technique c) FBC, Group and Crossmatch, Clotting profile, Specific factor assay Assess haemodynamic status, Oxygen (if required), Local pressure dressing Assessment by surgeons if bleeding vessel requires ligation, Transfuse (whole blood, plasma), depending on clinical assessment, IV Vitamin K

1. A 5 year old boy returned from school a week ago with rhinorrhoea and a cough. Over the next two days the cough grew worse especially at night. He was subsequently admitted to the hospital where he had been admitted on 2 previous occasions with similar episodes. A diagnosis of asthma was made at the time of discharge and he was sent home on medications whilst his parents received counseling prior to discharge. A) Name 4 triggers that might set off an exacerbation of an asthmatic attack. (1 mark) B) Describe the likely management he received for his acute problem while on admission.(2 marks) C) Name 2 medications that he is likely to be sent home on and explain their role in the home management of his condition(1mark)

A- Cold,pollens,excercise,dust,animal fair B-Airway patency and breathing Intranasal oxygen Nebulized salbutamol Ipratropium bromide Iv/oral corticosteriod /hydrocortisone Lab[fbc,ABG], chest X-ray Inhaled C-corticosteroid to prevent exacerbation and reduce frequent use of SABA Inhaled short acting beta2 agonist to control symptoms

3. Kofi is a 4 year old boy who was rushed to the emergency room very lethargic and weak. This was associated with a high fever of 38 degrees Celsius of a day's duration. He started passing dark colored urine the day before and also complained of abdominal pain. Mother was very agitated as an older son had died at age 6yrs following a febrile illness during which he also had dark colored urine. He required to be transfused then. A) What 2 possible differential diagnoses can be considered as the likely causes for the passage of the dark coloured urine in Kofi?.(1 mark) B) Indicate how any 2 investigations would assist you determine the cause of the dark coloured urine. (1mark) C) Mention 2 problems that may result from this and how you would address them.(2 marks)

A-Severe malaria SCD[haemolytic crisis], G6PD B-RDT, HB electrophoresis C- Anaemia--Transfusion HYPOGLYCAEMIA 10%glucose iv 5ml/kg bolus NS in 10%glucose AKI---IV fluid

5) A 5 year old boy presents with facial swelling which mother says she noticed only the day before. a) Name 2 possible diagnoses b) How would you investigate this patient? List 3 investigations and the likely results to support your diagnosis. c) How would you manage this child? d) What is the likely prognosis of this child?

Acute glomerulonephritis, Nephrotic syndrome, Angioneurotic oedema Urine microscopy- heavy proteinuria (Nephrotic), presence of granular casts, red blood cells (acute glomerluonephritis (AGN): Serum lipids- hypercholesterolemia in Nephrotic, LFTS- hypoalbuminemia in Nephrotic, hypocomplementemia in AGN, raised blood pressure in AGN, ASO titre (AGN) AGN: Course of antibiotics, bed rest, bp monitoring, anti hypertensives if needed, input-output chart; Nephrotic syndrome: Oral prednisolone, low salt, high protein diet, cyclophosphamide, levamisole for steroid resistant cases, monitoring of urine; antihistamines and I/V hydrocorticsone for angioneurotic oedema Nephrotic syndrome: 1/3 resolve directly, 1/3 have infrequent relapses, 1/3 have frequent relapses or are steroid-dependent; AGN- excellent prognosis; angioneurotic oedema- good prognosis

3. A7-year-old girl with newly diagnosed Burkitt's Lymphoma involving the jaw and abdomen is given IV Cyclophosphamide. The following day, she develops oliguria. a) What is the most likely diagnosis? b) Give 3 reasons to justify your diagnosis in c) List 4 key features of this condition: e) Outline 2 important steps in the management of this patient with justification:

Acute kidney injury 2do to Tumour lysis syndrome Newly diagnosed Burkitt's, Bulky disease (jaw & abdomen); Received chemotherapy Hyperkalemia, hyperphosphatemia, hyperuricaemia, hypocalcemia, elevated serum creatinine Hyperhydration, Allopurinol/Urate oxidase, treat specific electrolyte abnormalities

4. A 6-year-old boy presents with fever, respiratory distress and physical findings of a new heart murmur. You are informed that he had a sore throat three weeks ago which was managed at home. a) What is the most likely diagnosis? b) Briefly explain the cause of this condition: c) List 2 aspects of the primary prevention of this condition: d) What is the most important aspect of the outpatient follow up of this patient?

Acute rheumatic fever Rheumatogenic strains of group A beta haemolytic streptococci; susceptible host; abnormal immune inflammatory response; cross reactivity Prompt and complete treatment of sore throats, reduce overcrowding, improved public education and awareness IM Benzathine penicillin OR oral penicillin to prevent recurrence

4) An 8 year old girl presents in the ER. She is a known sickle cell anaemia patient. She complains of fever and abdominal pain a) Name the different types of sickle cell crises? b) What is the likely diagnosis? c) Name 5 complications of sickle cell anaemia d) How would you manage her?

Aplastic, Haemolytic, Vaso-occlusive and Sequestration Sickle cell anaemia with vaso-occlusive crisis Sensoneural hearing loss, cerebrovascular accidents, retinopathy, Acute chest syndrome, hepatopathy, infections involving virtually every organ system ( pneumonia, osteomyelitis), priapism, avascular necrosis, leg ulcers Do lab investigations- Full Blood count, blood film for malaria parasites, biood cultures, urine microscopy and culture. Treat with analgesia, intravenous fluid therapy, antimalarials (if malaria), antibiotics if infection

1) A 10 month old child is admitted with fever and fast breathing. a) List 3 differential diagnoses b) What are the most likely causative organisms? c) What laboratory investigations would you do to confirm your diagnosis? d) How would you manage one of the diagnosis you have listed above?

Bronchopneumonia, bronchiolitis, severe malaria, tonsillitis, pharyngitis Streptococcus pneumoniae, Haemophilus influenzae, respiratory syncytial virus, rhinovirus, staphylococcus aureus, staph pyogenes FBC, Bf for mps, sickling: Chest x-ray, Blood C/s Depends on disease pathology

5) A 3 day old infant is brought to you at the clinic. The mother complains that the baby is not feeding well and is not active. Temperature is 38.5"C. a) What other 3 symptoms would you ask for? b) What is the most likely diagnosis? c) What laboratory investigations would you like to perform? d) How would you treat this patient?

Danger signs Convulsion, Tarchypnoea grunting. chest indrawing Hypothermia, central cyanosis Hyperthermia Neonatal sepsis RBS, FBC, Blood C/S, urine R/E, urine m/c/s Intravenous or intramuscular antibiotics (Crystalline penicilin, Gentamicin, Ampicillin, Cefotaxime, Cloxacillin)

3) A 11/2 year old girl has been rushed to your consulting room having seizures. a)List any 5 additional bits of information you may require b) List S important examination findings that would be useful to make a diagnosis c) List 3 laboratory investigations you would do d) How would you manage this patient?

Duration of seizures, no of times it has occurred, any sphincteric incontinence, any preceding fever, has child been unwell, is this the first episode in life? etc Presence of fever, jaundice, anaemia, inflamed eardrum or tonsils, respiratory distress, added respiratory signs, presence of a murmur, hepatosplenomegaly. consciousness level, neck stiffness, positive Kernig's Full Blood Count, Blood film for malaria parasites, Random Blood Sugar, Lumbar puncture, blood culture, urine R/E and C/s Depending on underlying pathology eg malaria- antimalarials, antipyretics, hypoglycemia, need to correct, if severely anaemic- transfuse

3) A one week old infant is brought to the consulting room with history of swellin over the Right clavicle a) List 3 additional bits of information you would like find out in the history b) List 2 differential diagnoses? c) What additional investigations would you like to do? d) How would you manage this patient?

Duration of symptoms, birth weight, mode of delivery, ? traumatic delivery? Clavicle fracture Chest X-ray Reassure mother

A 5 year old presents to the ER with a 3 day history of fever and jaundice. a) What 3 additional bits of information would you like to find out? b) List 3 differential diagnoses c) List 3 laboratory investigations you would like to do on this child? d)Depending on your diagnosis, how would you manage this patient?

Duration of symptoms, grade of fever, darkened urine?, bone pains?, history of sickle cell anaemia etc malaria with IVH, sickle cell anaemia, viral hepatitis, Enteric fever Full Blood Count Blood film for malaria parasites 3) Hb electrophoresis 4) Blood culture 5) urine R/E 6) urine C/S -Malaria: Antimalarials (ACT e.g Amodiaquine/ Artesunate; Artemether/ Lumefantrine; ), antipyretics -Sickle cell anaemia: Antimalarials, analgesia, liberal oral fluids, antipyretics -viral hepatitis: Symptomatic -Enteric fever: Antibiotics, antipyretics

3. A2-year-old girl is seen in the emergency room with a 3-day history of fever and seizures on the day of presentation a Outline 5 important points you would obtain from the history, indicating their relevance: b) List 3 criteria that would be needed to classify her seizures as complex febrile seizures: c) List 2 important bedside tests you would perform for this patient: d) What is a possible long term complication of febrile seizures?

First time of presentation Duration of seizure If it reoccurs within 24hrs Family history of epilepsy Infection Feeding History of malaria more than 1 episode in a 24hour period, initially focal with secondary generalization; lasts longer than 15 minutes Random blood sugar;.RDT. Malaria antigen testing Increased risk of epilepsy

1. A3-year-old child is suspected to have Down's syndrome a) List 4 physical features that might be present: b) List 4 complications of Down's syndrome: c) List the genetic changes that can result in Down's syndrome: d) How would the diagnosis of Down's syndrome be confirmed?

Flat occiput Flattened facial appearance Epicanthal fold Upward slanting palpebral fissure Protruding tongue Small nose ear and mouth, Short extremeties Low IQ, Reduced tone, congenital heart disease, duodenal atresia, Infection, Leukaemia, Alzheimer, Hirschprung.congenital hearing loss Translocation, Non-dysjunction, Mosaicism Karyotyping

2. A3 day old baby is brought to the emergency room with a history of jaundice that has progressively worsened over the past 48 hours a) List 2 important differential diagnoses: b) Based on your diagnoses in (a), briefly outline 4 important points you would obtain from the history, with justification: c) For each of your diagnoses in (a), indicate the confirmatory/diagnostic test: d) List 2 interventions for the management of jaundice in this baby, with 2 complications of each intervention:

Haemolytic disease of the newborn (ABO or Rh incompatibility), Neonatal Sepsis, G6PD deficiency, Red cell membrane defect e.g. Hereditary spherocytosis b)Parents blood group Previous child with similar presentation History of infection during last stage of gestation History G6PD Mode of delivery Haemolytic disease of the newborn - Blood groups of baby and mother with antibody screen; G6PD deficiency - G6PD screen; Neonatal Sepsis - Blood culture; Hereditary spherocytosis Osmotic fragility testing Phototherapy. dehydration, Rash,diarrhea,hyper\hypo thermia Exchange blood transfusions. bleeding tendency,infection,haemolytic reaction,sepsis

4) A 6 year old boy presents to you with wheezing and difficulty in breathing a) What additional information would you like to ask for? b) What is the most likely diagnosis. Give 2 differentials c) List 2 investigations you would like to carry out d)How would you manage this child?

How long have symptoms lasted for, any fever, cough, preceding coryza? is he a known asthmatic, and history of foreign body ingestion, is this the first episode in life, any family history of asthma or atopy Bronchial asthma. Differentials include pneumonia, foreign body aspiration etc Full Blood Count, Chest x-ray, peak flow Nebulise Salbutamol, Oxygen, intravenous or oral antibiotics, intravenous fluids if unable to drink

2) A 3 year old boy was rushed into the ER with the history that he has just ingested kerosene a) What additional history would be beneficial to you? b) List 4 important examination findings you will look for to help you determine if the child is critically ill? c) What 2 systems are likely to be most affected? d) How would you manage this child?

How much was ingested? has any attempt been made to induce emesis? Has any other treatment been given? Is he coughing or having fast breathing? any confusion or lethargy? Acutely ill-looking, febrile, respiratory distress, tachypnoea, reduced air entry, crepitations The Respiratory and the Central Nervous systems The child needs to be admitted for observation of vital signs, if there are signs of respiratory involvement, give Oxygen, intravenous antibiotics, DO NOT INDUCE EMESIS

1. A 2-year-old child is brought to the emergency room at 4a.m. with cyanosis and severe respiratory distress. His mum says he has been cyanosed since age 8 months and frequently squats while playing. a) What is the most likely diagnosis? b) List 2 factors that may have precipitated this condition: c) Briefly outline 4 important findings that might be elicited on physical examination d) List 3 investigations you would do with justification:

Hypercyanotic spell or "Tet" spell b) Infection, dehydration, crying, movement, exercise/playing c) Poor growth on anthropometry, digital clubbing, ejection systolic murmur in pulmonary area (may be less audible), loud, single s2, arterial blood gases, chest x-ray, ECG, ECHO, FBC, Septic screen (if febrile) -Must indicate relevance of each test listed child in knee chest position Give oxygen Hydration Morphine sulphate Beta blockers.propranolol Correct electrolyte imbalance. Iv Phenylephrine Refer to cardiology Complication Cardiac failure Recurrent respiration infection DDx Tretralogy of fallot Transposition of great vessel Tricuspid atresia Total anomalous pulmonary venous return Truncos arteriosus

5. Baby Kay, a 12 week old infant is brought to the hospital with complaints from the mother of poor feeding at the breast over the last two weeks. Parents also report that he seems to be breathing faster than before. Initial assessment reveals a respiratory rate of 70 breaths per minute with sub- costal indrawing and basal crepitations. Heart rate was 160 beats/ minute. The precordium was active and a grade 4/6 pan systolic murmur was heard on auscultation. The peripheral pulses appeared normal. The liver was enlarged at 3cm below the right costal margin. A) What further questions will you ask the mother to help you determine what is wrong? (1 mark) B) Indicate the investigations you will request and why.(11/2marks) C) What would be your initial management plan? (11/2 marks)

Is there Increase fatigability Does the child fail to thrive Does the child cbild fail to grow Cough, cynanosis Infections TORCH Sweating while feeding Difficult feeding Chest X ray-cardiomegaly,kerly b line EKG-ventricular hypertrophy Echo--structural deformity Fbc,bue-cr, Hb electrophoresis, pulse oximetry for oxygen saturation Prop up child in cardiac position Ensure airway patency and breathing Intranasal oxygen Iv furosemide Spironolactone Beta blockers

4. Regarding paediatric HIV infection a) List 2 conditions that are categorized as Stage V HIV infection: b) Briefly outline 3 reasons children with HIV are at high risk of malnutrition: c) What is the main limitation of diagnosing HIV infection in infants? d) List 3 social problems children with HIV might encounter:

Kaposi sarcoma Extra pulmonary TB Severe wasting Cerebra toxoplamosis HIV encephalopathy CMV virus infection persistent diarrhea, sub-optimal feeding practices, likelihood of opportunistic infections etc. c) Persisting maternal antibodies Stigmatisation Discrimination School drop out, Depression

4. A day old neonate delivered at home is brought to the ER with a history poor suck fever and seizures. a) List 4 other clinical features this child may have b) List 2 differential diagnoses c) list 4 investigations you will do d) name 2 anticonvulsants you will use to abort the seizures

• excessive cry • irritability • tachycardia • tachypnea • bulging anterior fontanelle • lethargy • Neonatal sepsis • Meningitis • Birth asphyxia • FBC, RBS, Urine R/E and C/S • Blood C/S • BUE and CREATININE • Head USG • Lumber puncture • phenobarbitone • IV phenytoin • IV midazolam

2. Akua is 7 year old girl who presented to the OPD with a five day history of feve which was not responding to paracetamol. She complained further of bone pai making it difficult for her to walk. A) What 2 differential diagnoses would you consider?(1mark) B) Give 4 further questions that would be helpful in determining the underlying cause.(1mark) C) For one of the above mentioned possible diagnoses, what 2 significant clinical signs would you elicit and why? (1mark) D) Name 2 investigations and explain how they will assist you in arriving at definite diagnosis (1mark)

Sickle cell disesase Malaria Rheumatoid fever Family history of SCD, Previous crisis,dark cocacola urine, yellow skin, history malaria,do you sleep under ITN SCD=Frontal bolsing,severe pallor,Hepatosplenomegaly,gnathopathy,dactylia Malaria=Hepatomegaly,mild pallor, SCD-Hb electrophoresis,/ss or sc=sickle cell disease fbc anamia or leukocytosis possible infection Malaria=RDT/antibody, thin and thick film=type of parasite [parasitaemia]

4. A 2 year old boy presents at the ER with fever, cough and difficulty in breathing of 3 days duration a. List 2 differential diagnoses b. List 4 chest examination findings suggestive of a consolidation c. list 4 important laboratory investigations you will do d. list 2 therapeutic procedures you will do if this child had pleural effusion

Pneumonia Bronchiolitis • Pleural effusion • Pulmonary tuberculosis • Percussion note is dull • Air entry is reduced • Breath sounds are bronchial • Vocal resonance is increased Tactile fremitus is increased • FBC • HB electrophoresis Retroscreen • Blood c/s Chest x-ray Pleural tap/aspirate Chest tube insertion

1. A 10-year-old boy presents to the clinic with a limp and a swollen right knee. a) List 2 differential diagnoses: b) Outline 4 important points in the history indicating their relevance: c) For each of your differential diagnoses, indicate 1 diagnostic investigation and the expected result. d) For any one of your differential diagnoses, outline 2 key principles in the immediate management of this child:

Septic arthritis of right knee joint; haemarthrosis of right knee joint from haemophilia, juvenile idiopathic arthritis, osteosarcoma of distal femur, Fever, joint pains, impared range of motion, history of previous joint disease, Trauma Septic Arthritis.screen synovial fluid for crytals via polarizing microscopy Haemahtrosis for haemophila .factor vii and ix Osteosarcoma.plain x ray of joints management Drainage of synovial fluid Antimicrobial therapy Immobilization of joints to control pain

4. A9-month-old with sickle cell disease is rushed into the emergency room with severe pallor a) What are 3 differential diagnoses in this patient? b) Outline 4 points you would elicit from the history to aid diagnosis and management. c) Apart from a full blood count, list 2 key laboratory tests you will order for this patient: d) Outline 2 important aspects of the outpatient follow up care of this child, based on the differential diagnoses in (a):

Splenic sequestration, Aplastic crises, Hyperhaemolysis Joint pain, abdominal pain jaundice,coca cola like urine, history of malaria, fever Group & crossmatch, BUE/Cr, Blood film for malaria parasites or malaria antigen testing, Blood culture (if fevrile) Ensure vaccinations are up to date, teach parents to palpate spleen, educate on malaria prevention, educate on recognition of danger signs (anaemia, jaundice, fever, symptoms of hypovolemia), adequate hydration etc.

2) A5 year old girl has been on oral steroid treatment for several months. Her mother complains that she has put on a lot of weight but has a normal appetite a) What will you tell the mother is the reason for her complaints? b) List 4 other possible associated clinical signs c) Name 3 clinical conditions that require the use of oral steroids d) What other 2 childhood illnesses are associated with facial swelling?

Steroid toxicity Growth failure or short stature, face and trunk obesity, hirsutism, striae, hypertension, bruising, carbohydrate intolerance, osteoporosis, psychological problems Nephrotic syndrome, Leukaemia, Bronchial asthma facial Nephrotic syndrome, Acute glomerulonephritis, angioneurotic oedema, PEM Kwashiorkor, congestive cardiac failure

1) A 5 month old male infant previously well, is admitted following 2 days of diarrhoea and vomiting. On admission, the child is noted to be very lethargic with prolonged capillary refill time with temperature of 38°C and wt=6.3kg. a) List 4 other signs of dehydration you would look for? b) What is the likely fluid deficit? probably c) What would be your choice of intravenous fluids? d) How would you rehydrate this child?

Sunken eyes, depressed fontanelle, dry mucous membranes, prolonged capillary refill time, poor skin turgor, small volume pulses, oliguria Assuming the child is severely dehydrated, the fluid deficit is probably about 10% loss= 10/100 x 6300= 630mls Normal saline or Ringer's lactate 20-30mls/kg over 1hour, then 70-80mls/kg over 5hours

1. A 6 month old male child is brought to the ER with excessive cry. Mother noticed child has been passing bloody stools which she described as "red jam'. a. What is the most likely diagnosis? b. List 2 clinical features this child may have c. List 3 diagnostic tests you will do d. List 2 treatment options

• intussusception • vomiting • colicky abdominal pain mass in right hypochondrium • Abdominal X-ray • Ultrasound scan • Barium enema • Hydrostatic reduction • Pneumatic reduction • Surgical reduction

5. A4-year-old girl presents to the out patients' department with a 1 week history of progressively increasing generalized oedema. This is the second similar' episode in the last 6 months. Her Spoz in room air is 96%. a) Outline 4 key points you would like to obtain from the history, with justification b) Outline 4 key aspects of the physical examination of this child, with justification You admit the patient and two days later, she develops afebrile, generalized tonic, clonic seizures. Random blood sugar level is normal. c) List 1 important reason for seizures in this child d) What medication might be used to emergently abort the seizures (include the route of administration)?

Unintentional weight loss,early morning puffness, foamy urine Nausea and vomiting,parasitic infection,lupus Ascitis, pleural effusion, periorbital and genital edema,abdominal discomfort and pain, severe cerebral thrombosis, hypotension Hypertension IV/Rectal diazepam

1) A mother brings her week old baby to the clinic with the complaint of a swelling on one side of his head. On examination he is essentially well-looking apart from the swelling. a) What 3 questions would you like to ask the mother? b) Name 2 possible differential diagnoses and how would you differentiate between the two of them? c) List 2 possible complications d) What would be your management for any of your diagnoses?

Was the delivery by spontaneous vaginal delivery or by caesarean section? was the delivery traumatic? Is the swelling still growing in size? Is it painful? Cephalhaematoma, subgaleal haematoma. Cephalhaematoma is bleeding below the periosteum confined within the margins of the skull sutures usually involving the parietal bone. It resolves over several weeks. Subgaleal haematoma usually crosses suture lines. Blood loss leading to anaemia, jaundice Cephalhaematoma - reassure mother. will resolve spontaneously. Subgaleal haematoma- observe closely for anemia and jaundice, secondary infection and manage accordingly

3) A 3 year old child is rushed into the ER looking very pale and very lethargic a) List 3 additional pieces of information you would require from the history b) List 4 laboratory investigations you would do c) Give 3 possible differential diagnoses d) How would you manage this patient?

When did illness start? What are the symptoms? Is there a febrile illness or passage of dark urine? is she a known sickle cell anaemia patient? Full Blood count, Grouping and Cross-matching, blood film for malaria parasites, sickling or Hb Electrophoresis, G6PD assay Severe anaemia secondary to 1) severe malaria 2) Sickle cell anaemia in crisis haemolytic, sequestration, aplastic), 3) Sepsis 4) Enteric fever 5) G6PD deficiency After taking samples, transfuse and treat underlying cause

5) A 3 month old baby is rushed into the ER with difficulty in breathing and poor feeding a) List 5 additional bits of information that would help you make a diagnosis b) Name 3 differential diagnoses? c) What laboratory investigations would you do? d) How would you manage any of these conditions?

When did symptoms start? Is there fever? is there cough? Has the baby had immunisations? How is the baby fed? is baby growing normally? is there any discolouration of lips or hands? Bronchopneumonia, Bronchiolitis, Congenital heart disease, Aspiration pneumonitis Random Blood sugar, Full Blood count, Chest x-ray, sickling or Hb Electrophoresis, blood culture Bronchopneumonia: Intravenous antibiotics, Oxygen, intravenous fluids; Bronchiolitis: Oxygen, intravenous fluids, supportive management; congenital heart disease: diuretics, oxygen; aspiration pneumonitis- antibiotics, oxygen, intravenous fluids

2. A 4 year old boy is rushed to the emergency room with a 3 day history of fever and convulsion which occurred 2 hours ago. Blantyre coma scale is 2/S a) List 2 differential diagnoses b) What will be your initial assessment c) List 2 bedside tests you will do immediately after your initial assessment d) List 2 medications you will use for the treatment of the differential diagnoses

cerebral malaria meningitis encephalitis intracerebral abscess assess airway breathing and circulating RBS, RDT IV Artesunate / IM artemether / IM quinine for cerebral malaria IV ceftriaxone for meningitis

3. A neonate is referred on the day of delivery with a midline swelling at the lower back a) List 3 other structural abnormalities that may be associated with this condition: abnormalities b) List 3 key points that should be obtained from the history: c) List 4 key aspects of the physical examination this baby: d) Apart from a paediatrician, list 3 other specialists that would be involved in the management of this baby:

hydrocephalus, talipes equino varus, heart malformations, genitourinary tract abnormalities affected sibling, maternal intake of folate, maternal diabetes melitus especially pre- gestational Examine mass: anatomic location, size, whether infected etc; Measure head circumference and plot , Examine limbs: motor/sensory, presence of malformations; Palpate abdomen: bladder, kidneys, Check for patulous anus, Examine heart Neurosurgery, Orthopaedics, Cardiology/Cardiothoracic Surgeons, Clinical Psychologist, Nephrology/Urology, other relevant

4.Peter is a one yr old boy who was admitted to the ward with severe acute malnutrition. He appeared very alert and agitated and had the appearance of an old man in the village. His 18 yr old mother is a head porter at the market and appeared pregnant again. A) Give 4 possible reasons why Peter is in this state.(2 marks) B) List 4 clinical features you would expect to find in this child.(2 marks)

marasmo A-Poor feeding The child is not been feed enough Wrong formula Child neglect Adolescent mother[no knowledge of feeding) Low socioeconomic status Short intergestic interval B-Muscle wasting Baggy pant Prominent bones Cachetic Muac<11.5 No edema

2. A 4 year old boy presents at the OPD with generalized swelling of a week's duration. Swelling started from the face ,which was initially worse on waking up but decreases toward the end of the day. a) What is the most likely diagnosis? b) List 4 differentials for generalized body swelling c) List 4 diagnostic features of the most likely diagnosis d) What will be your first line treatment for this condition

nephrotic syndrome chronic renal failure • nephritic syndrome • congestive cardiac • severe acute malnutrition • liver failure/cirrhosis protein losing enteropathy • edema • marked proteinuria hypoalbuminemia • hyperlipidemia • prednisolone

5. An 18-month-old child has acute respiratory distress and fever. a) List 3 findings that might differentiate between upper and lower respiratory tract disease in this patient: b) Give 1 example each of upper and lower respiratory tract conditions that would be relevant differential diagnoses in this patient: c) For each example in (b), indicate the most likely cause: d) For each example in (b), indicate 1 key investigation you would request and the expected findings:

presence of stridor, change in voice quality, drooling, positioning eg, neck retraction Upper: croup, acute epiglottitis; Lower- bronchiolitis, pneumonia For bronchiolitis - RSV epiglottitis..parainfluezae For bronchiolitis -chest x-ray showing hyperinflation and atelectasis Croup steeple sign Epigiotitis. Thumb sign

3. A2 year old boy is rushed to the emergency room having ingested kerosene an hour ago Mother gave the child palm oil to induce vomiting SPO, is 75% and there are crepitations in the chest. a) what is the most likely diagnoses? b) list 2 other signs that may be present in this child • c) describe 4 components of your management d) what 2 important advice will you give to the mother

• Aspiration pneumonia + kerosene ingestion or • lipoid pneumonitis + kerosene ingestion • cyanosis • Tachypnea • Tachycardia • flaring • use of accessory muscles of respiration- intercostal recession, subcostal recession • lethargy or irritability • put on intranasal oxygen • give maintenance intravenous fluids • put on IV antibiotics • maintain NPO • monitor respiratory rate and oxygen saturation • Keep chemical and medicine high up in a locked cupboard out of reach and sight of children avoid giving child palm oil to induce vomiting after chemical ingestion • ensure medications are in a child resistant container • leave chemicals and medicines in their original container • put child resistant locks on most cupboard.

5. A5 year old boy who has asthma is rushed to the emergency room with difficulty in breathing, chest tightness and wheezing. He used his salbutamol inhaler twice prior to presentation but there was no improvement. a. What other important history will you take? List 2 b. List 4 dlinical features suggestive of severe acute exacerbation of asthma C. His oxygen saturation is 75%. Describe 4 components of your management d. List 2 common side effects of salbutamol

• Can child complete full sentences • Has child ever been admitted to ICU on account of severe asthmatic attack? • Has child ever been ventilated Lethargy • Low oxygen saturation • Cyanosis • Silent chest • Tachycardia/ bradycardia • Use of accessory muscles of respiration • Inability to complete full sentences • Put on intranasal oxygen • Nebulise with salbutamol • Nebulise with ipratropium bromide • Set up intravenous fluid • Give IV hydrocortisone • Monitor oxygen saturation • tachycardia • Shaking/tremors • Headache • Anxiety/ nervousness • Dry mouth

2. A 5 year old known sickle cell disease patient, genotype SS presents with a swollen left lower limb and fever of 3 days duration. There is no history of trauma a. List 2 differential diagnoses b. List 2 common causative organisms C. List 4 important investigations you will request d. Describe 2 components of your management

• Cellulitis • Osteomyelitis • Pyomyositis Septic arthritis • Staphylococcus aureus • Salmonella spp • Streptococcal spp • Enterobacter • FBC, ESR • Blood C/S • X-ray of the limb • CT scan • MRI • Ultrasound for abscess • IV antibiotics • Analgesics • IV fluid • Elevation of limb

3. A 3 day old male term neonate is brought to you with a history of having yellowish discolouration of the eyes and poor feeding noticed by the mother a day before presentation. a) List 2 ways neonatal jaundice can be classified b) List 4 possible causes of jaundice in this newborn c) List 4 investigations you will request d) Describe 2 components of your management of this child

• Conjugated hyperbilirubinaemia and unconjugated hyperbilirubinaemia • Direct and indirect hyperbilirubinaemia • Physiological and pathological jaundice • Mild , moderate and severe jaundice • Breastfeeding jaundice • Sepsis • G6PD deficiency • ABO incompatibility Rhesus isoimmunisation • FBC, blood film comment • LFT • Blood C/S, urine R/E and C/S Blood group of baby+ direct Coombs test • Blood group of mother + indirect Coombs test • Start phototherapy • Give IV fluids •. IV antibiotics for possible sepsis • Exchange transfusion if indirect bilirubin is above 340 umol/

1. A4 year old child is brought to the emergency room with a history of vomiting and passing watery stools of 2 days duration. Examination shows that child is lethargic with sunken eyes and reduced skin turgor. These is no fever a. list 2 other signs this child may have b. List 3 laboratory investigations you will do c Describe 4 components of your management of this child d. List 3 clinical features suggestive of hypovolemic shock

• Dry mucous membrane • Oliguria • Tachycardia • Slow capillary refill > 3 seconds • hypotension • FBC, BUE/CR, STOOL R/E and C/S • Intravenous fluid( normal saline or ringers lactate) for resuscitation • Correction of electrolyte imbalance • Monitor urine output • ORS • Zinc tablet • frequent assessment of hydration status • Cold clammy peripheries • Increased capillary refill> 4 sec • tachycardia weak thready pulse • lethargy • hypotension

5. A newborn is referred to the pediatric ward on account mother having retroviral infection a) list 2 questions you will ask the mother to assess baby's risk b) what will you tell mother about feeding of the baby and why c) what antiretroviral medication will you administer to a high risk baby and for how long d) what test will you request to diagnose retroviral infection in this baby and when will you do this test?

• Is mother on antiretroviral drugs? • When did mother start ARVS? • Was mother compliant with her medications? • Mode of delivery of baby • Advise mother to do exclusive breastfeeding or exclusive formula feeding and not mixed feeding • Mixed feeding will increase the risk of acquiring HIV infection through the gut • Syrup zidovudine and nevirapine 12 weeks • PCR 1-3 days of life and 6 weeks

5. Al year old boy is brought to you at the OPD with a history of poor feeding and poor weight gain noticed after baby was weaned. She weighs 4kg. Her birth weight was 2.9kg. Child has severe acute malnutrition a) list 4 anthropometric measurements you will take b) what will be her expected anthropometric measurements? List 2 c) list 4 conditions in this child that will need emergency treatment d) what solution will you recommend for treating diarrhea in this patient?

• MUAC (Mid Upper Arm Circumference) • Weight for age • Height for age • Weight for height/ length • MUAC <11.5CM • Weight for length <-350 • Hypoglycemia • Shock • Diarrhea • Infection Anemia d) RESOMAL

4. A 2 year old girl is rushed to the emergency room with hot water burns. This happened an hour prior to presentation. a. Describe 2 things you will do immediately b. What will be your major concerns? List 2 c. Describe 4 components of your management d. List 2 long term complication of burns scarring

• assess airway, breathing and circulation • determine the total burns surface area (TBSA) and hydrate give analgesic to relieve pain • infection • fluid loss • give prophylactic antibiotic • rehydrate with IV fluid based on surface area involved • Analgesics for pain relief Wound dressing with silver sulphadiazine • scarring • contractures • amputation • psychological trauma

3. A 3 year old child is rushed to the emergency room convulsing. She has a fever a days duration a Describe 4 components of your immediate management b) List 2 features of a simple febrile convulsion c) List 2 features of a complex febrile convulsion d) List 2 common differential diagnoses

• assess airway, breathing and circulation • put on oxygen • check random blood sugar and correct hypoglycemia with 10% dextrose • abort convulsion with rectal or IV diazepam • antipyretic • convulsion is generalised tonic clonic • does not last more than 15 minutes • usually occurs once in 24 hours • could be focal • lasts more than 15 minutes multiple episodes occur within a 24-hour period febrile convulsion secondary to malaria,otitis media, tonsillitis etc • meningitis • cerebral malaria encephalitis

1. A 5 year old child presents at the emergency room with fever and cola-like urine. Her hemoglobin level is 4.4gidi a. List 2 common causes of cola-like urine (hemoglobinuria) • b. List 4 important laboratory tests you will do C. Describe 4 aspects of the acute management of this child d. List 2 things you will do if the child develops a transfusion reaction

• malaria with intravascular hemolysis • sickle cell disease with hyperhaemolytic crises • sepsis • G6PD deficiency • FBC • HB electrophoresis • BUE &CR • BF for malaria parasites/ RDT • G6PD deficiency test • Blood C/S • urine R/E and C/S • grouping and crossmatching • Blood film comment • put on intranasal oxygen • set up intravenous fluids • serial urine collection • transfuse blood • broad spectrum antibiotics for sepsis . administer paracetamol • V artesunate or injection artemether if malaria parasites present -stop blood transfusion • -run normal saline • -check blood unit label and patient's identification to ensure right blood was given -give IV hydrocortisone -send residual blood and freshly collected blood sample to the blood bank to investigate a transfusion reaction