Note from Dr. Hobbs

The goal of the Departmental Exam is for us to hear your thought processes as you approach a common clinical condition in pediatrics. It will be a discussion with more emphasis on your differential and approach to work up than on finding one specific answer to the case presented you.

As you prepare for the exam I would not ask you to memorize everything there is to know about a topic such as failure to thrive, jaundice, lethargy, anemia, etc. I want to see that you know the basics at the top of the differential regarding these complaints in children and that you can think through a case based on the history we give you. You should demonstrate the first steps in evaluation of the problem presented, but you don't need to know all the subtleties about how it is managed at this stage. The level of content you need to know is about at the level of what is demonstrated in the cases in the Pediatric Clerkship Guide, one of the books we lend you for the course.

To help you I'll include here an example of what we're looking for - though this is not one of the 10 cases we will use.

Case stem:

A 2 yo with seizure.

Case you could get in the exam:

A 2 yo girl is brought by EMS after a seizure that occurred at her home. She was not observed at the onset; her mother found her on the floor in the play room in generalized tonic clonic seizure. The mother called EMS immediately and when they arrived 8 minutes later the seizure had stopped and the child was groggy. The child is developmentally normal and previously well, though mom kept her home from daycare today because she was sleepy and had a poor appetite this morning. On PE the child is responsive but somewhat sleepy, with T 39.7 deg C, HR 156, RR 26, BP 98/64, O2 sat 96% on RA. PERRL, EOMI, mm slightly dry, neck seems supple, no LAD, lungs clear, RRR with brisk CRT, abd soft and nontender, normal reflexes and tone, no rash.

Questions you might be asked in the exam:

List a differential diagnosis you would consider for this patient.
Describe your initial diagnostic approach.

What we would want to hear in the answer:

My differential would include simple febrile seizure versus meningitis. Toxins could also cause seizure, or head trauma. Seizure could also be due to electrolyte abnormality though she's not likely to have that as a well 2 year old. Given the fever I would focus on febrile seizure and meningitis. Febrile seizures should have a brief post-ictal state - so I would watch her recovery from seizure. If she is lethargic or if I can't rule out meningitis by exam I would need to do an LP to be sure. If it is a simple febrile seizure I'll think about what the cause of her fever is and address that if I need to.

What fits for febrile seizure is her age, that she is developmentally normal, that the seizure was brief and generalized tonic clonic.

What worries me that it could be meningitis is that you say she's groggy.

We are looking for you to be logical in your approach and have a basic foundation of medical knowledge to work with regarding common pediatric problems. We're not trying to trick you with anything on the oral exam. We are hoping everyone will do very well with this.

Good luck in your studying for this and the shelf, and enjoy your time in the clerkship!

- Rick Hobbs