Transcript Ewww...the Boards 9/8/09

Ewwww…the Boards
Jillian Parekh, MD
September 8, 2009
Thoughts:
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The boards cover a HUGE amount of
information
Boards come at a very stressful time (soon after
you graduate) when you are adjusting to
fellowship or a new job
The more you familiarize yourself with the
material the better
Plan:
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Discuss a good study plan
Meet on a regular basis and go over the most
difficult topics (as chosen by you)
Share the work amongst us
Make it fun and painless
By the time you graduate, you will have gone
through a lot of the info once and have good
references
Things to keep in mind:
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You have lots of time…it is very early
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But the more you familiarize yourself, the better
You are being exposed (over exposed) to lots of
good pediatrics during residency
You are all going through it together…use each
other as supports
Stick to studying methods that have worked for
you in the past (Step 1)
The Basics
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1 day test (October 18th, 2010)
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All questions are multiple choice (~350)
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Regsitration: Dec 1, 2009 – Feb 25, 2010 = $2,030
Late Registration: Feb 26 – May 6 =$2,335
To apply go to abp.org
Need a license to take the test
Two 3.5 hour sessions
Test is on paper
Long lunch break in between sessions
Image questions are scattered throughout test
Most questions have a long clinical stem
2008 national pass rate was 77.7%
Plan to get hotel for the night before (closest test sites are
Uniondale, LI or NJ).
Getting Started
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Most people use 3 months of dedicated study
Pick one main text
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Pick the text early on and use it during your rotations
Laughing your way
First Aid
Use text books only as a supplement to weak areas
Make a schedule
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Make it realistic (include social events, etc)
Save time for review at the end
Studying methods
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Go topic by topic (chapter by chapter)
Try to arrange topics according to your strengths
 Don’t cluster all the heavy stuff (Endo then MSK)
 Review PREP questions for that topic before
moving on
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Discuss material with friends
Questions, questions, questions
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Try to do about 5 years of PREP
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Remember that older years won’t be as accurate
Leave most recent years until the end
Study the answers, that’s where you learn the most
Do questions in random order or by systems (CDs)
Don’t worry…you will get A LOT wrong
Oh yeah…it’s normal to get A LOT wrong
Leave 2010 PREP for the end (do as a complete test)
Pictures
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There are not as many as there used to be
Read the question carefully, a lot of times you
don’t even need the picture to answer
Review Zitelli whenever you have free time
Flip through to look at all the pictures
 Great to look at it by systems with corresponding
review chapter
 The more you look at it, the better
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Typical boards questions:
1. 6 year old boy presents with 2 days of fever and noisy
breathing. No PMH. Missing his last DTaP and
MMR. On exam, he appears scared and toxic and has
labored respirations and a very harsh cough. He is not
drooling and can lie flat while you examine him. T:
103.5. RR: 35. HR: 168. BP: 107/68. Lungs are clear,
no murmur with benign abdomen.
 OF THE FOLLOWING THE MOST LIKELY
DIAGNOSIS IS:
What are you thinking?
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A. Bacterial tracheitis
B. Bronchitis
C. Epiglottitis
D. Foreign body aspiration
E. Laryngotracheobronchitis
The clues:
1.
6 year old boy presents with 2 days of fever
and noisy breathing. No PMH. Missing his
last DTaP and MMR. On exam, he appears
scared and toxic and has labored respirations
and a very harsh cough (brassy cough). He is
NOT drooling and CAN lie flat while you
examine him. T: 103.5. RR: 35. HR: 168. BP:
107/68. Lungs are clear, no murmur with
benign abdomen.
Answer:
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A. Bacterial tracheitis
B. Bronchitis
C. Epiglottitis
D. Foreign body aspiration
E. Laryngotracheobronchitis
Explanation:
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Bacterial tracheitis: superinfection from viral syndrome
(S.Aureus, Moraxella, nontypeable HiB). Resp distress b/c of
swelling at cricoid cartilage and thick purulent secretions.
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High fever, toxic with brassy cough
Epiglottitis: can’t lie flat, drools (dysphagia). Less common than
tracheitis secondary HiB vaccine.
Croup: not normally highly febrile/toxic, usually < 3 y
Bronchitis: dry hacking cough, non toxic, preceded by viral URI.
FB aspiration: usually not febrile, not toxic, usually will describe
a 2-3 year old.
Developmental question:
2. You are seeing a young boy for his WCC. He
says “mama” and “dada”, “Bye” , “Up” and
“ball”. After exam, he sits on the floor in
front of his mother while playing with toy car.
He points to a toy he wants, and after his mom
tells him to go get it, he brings the toy to her.
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WHAT AGE IS THIS CHILD:
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A. 12 months
B. 15 months
C. 18 months
D. 21 months
E. 24 months
Clues:
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You are seeing a young boy for his WCC. He
says “mama” and “dada”, “Bye” , “Up” and
“ball” = 5 words. After exam, he sits on the
floor in front of his mother while playing with
toy car. He points to a toy he wants, and after
his mom tells him to go get it, he brings the
toy to her = follows a command.
Answer:
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A. 12 months
B. 15 months
C. 18 months
D. 21 months
E. 24 months
Explanation:
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15 m/o have 4-6 words, follow one step commands, can
understand instructions (without gesture), stoops to floor and
recovers to standing.
12 m/o : pincer grasp, takes a few steps, pulls to stand and
cruises, assists with dressing, 1 word besides mama/dada
(specific), follows single step command with gestures .
18 m/o: Self feeds with spoon, stacks 2 cubes, throws ball,
walks upstairs holding on, imitates household chores, 10-20
words.
24 m/o: Builds tower of 6 cubes, washes and dries hands,
removes clothing, kicks ball, jumps with 2 feet, >50 words
vocab, speech is 50% intelligible by strangers.
AAP guidelines:
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A 2 y/o boy presents with 3 days of diarrhea
and vomiting. Tolerating small amounts of
fluids. Moderately dehydrated on exam with
dry mucus membranes and HR of 145.
Of the following, the BEST management
for this patient’s fluid status is:
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A. Hospitalize with IVF and a restrictive bland diet
B. Hospitalize with IVF and gut rest for 24 hours
C. ORT at home followed by a clear liquid diet for 24
hours
D. ORT at home followed by a diet of fruits, vegetables
and meats
E. ORT at home followed by a restrictive bland diet
Clues:
3.
A 2 y/o boy presents with 3 days of diarrhea
and vomiting. Tolerating small amounts of
fluids. Moderately dehydrated on exam with
dry mucus membranes and HR of 145.
Answer:
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A. Hospitalize with IVF and a restrictive bland diet
B. Hospitalize with IVF and gut rest for 24 hours
C. ORT at home followed by a clear liquid diet for 24
hours
D. ORT at home followed by a diet of fruits,
vegetables and meats
E. ORT at home followed by a restrictive bland diet
Explanation:
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Mild and moderate dehydration can be managed at home with
ORT.
ORT replaces lost electrolytes (Na, Cl, K, bicarb) and glucose
and water.
Monitor ongoing losses – if excessive may need NG or IV
rehydration.
Once adequately rehydrated, resume normal diet.
Clear liquids and bland diet do not provide adequate nutrition.
Infants should receive human milk or their usual formula.
Avoid high sugar-containing liquids because of osmotic load.
Pattern recognition:
4. A 10 y/o girl presents to the ED with 1 day h/o
brown urine. She denies dysuria, urgency,
frequency and abdl pain. T: 37.1, BP: 165/97,
HR: 84, RR: 20. PE: moderate periorbital
edema, but otherwise normal. UA: moderate
blood, 4+ protein. Serum C3 is low, C4 is
normal.
 Of the following, the MOST likely cause of
the girl’s hematuria is:
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A. FSGS
B. IgA nephropathy
C. Lupus nephritis
D. Membranoproliferative glomerulonephritis
E. Postinfectious Acute glomerulonephritis
Clues:
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.A 10 y/o girl presents to the ED with 1 day
h/o brown urine. She denies dysuria, urgency,
frequency and abdl pain. T: 37.1, BP: 165/97,
HR: 84, RR: 20. PE: moderate periorbital
edema, but otherwise normal. UA: moderate
blood, 4+ protein. Serum C3 is low, C4 is
normal.
Answer:
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A. FSGS
B. IgA nephropathy
C. Lupus nephritis
D. Membranoproliferative glomerulonephritis
E. Postinfectious Acute glomerulonephritis
Explanation:
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Strong evidence of nephritis: gross hematuria, hypertension,
periorbital edema.
Biggest clue: low C3 with normal C4 = PIAGN
PIAGN most commonly follows a strep infection. Most recover
full renal function and C3 levels normalize in 6 weeks. HTN can
persist for up to 3 months secondary retention of salt and water.
Some can progress rapidly, requiring treatment with steroids and
IV cyclophosphamide or even dialysis -- renal outcome is then
guarded.
LOW C3 and C4 = membranoproliferative GN, lupus nephritis
NORMAL C3 and C4 = IgA nephropathy and FSGS.
Images:
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5. 10 y/o girl has had a rash for 4 days without other symptoms.
She is taking no medications. On PE she erythemtous cheeks
and a lacy, reticulated erythema involving the extremities.
OF THE FOLLOWING, THE MOST LIKELY DX IS:
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A. erythema infectiosum
B. phototoxic reaction
C. polymorphous light eruption
D. scarlet fever
E. systemic lupus erythematosus
Clues:
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10 y/o girl has had a rash for 4 days without
other symptoms. She is taking no medications.
On PE she erythemtous cheeks and a lacy,
reticulated erythema involving the extremities.
Answer:
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A. erythema infectiosum
B. phototoxic reaction
C. polymorphous light eruption
D. scarlet fever
E. systemic lupus erythematosus
Explanation:
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Erythema infectiosum is the most common clincal expression of
parvovirus B19. Fever, myalgia, or HA can precede the eruption
by 7-10 days. Rash starts as “slapped cheeks”, followed by lacy
reticulated, pink erythema of extremities or trunk. Less
commonly, can see “gloves and socks” syndrome. Eruption
fades after 3-5 days, but can return with exercise/heat.
Phototoxic drug reactions are not lacy/reticulated.
Polymorphous light eruption – hypersensitivity reaction to UV
light, occurs 1-2 days after sun exposure. Red papules on sun
exposed areas.
Scarlet fever – fine, rough feeling erythematous papules
associated with strep sx.
SLE – photosensitive malar rash, often involves bridge of nose ,
often is scaling.
Favorite Board Questions:
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6. A medical student rotating in your clinic tells
you about a 5 m/o he has evaluated. He reports
that the infant is fed goat milk exclusively and
asks you if this is adequate nutrition at this age.
Of the following, the MOST likely
deficiency in this infant is of:
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A. Folate
B. Iron
C. Niacin
D. Vitamin A
E. Vitamin D
Answer:
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A. Folate
B. Iron
C. Niacin
D. Vitamin A
E. Vitamin D
Explanation:
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Goat milk is used as the exclusive source of
nutrition in some countries. Its fat can be
digested more easily than fat in cow milk.
Deficient in iron, vitamin D, and ESPECIALLY
FOLATE.
Deficiency in folate can result in ineffective
erythropoiesis and megaloblastic anemia.
Can see macrocytosis and hypersegmented
neutrophils on CBC.
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7. You are evaluating a 3 y/o M in the ED for fever.
His mom tells you that he had been well until yesterday,
then developed fever to 103 (orally). +clear nasal
discharge, cough and 1 episode of emesis. At time of
your evaluation he is eating chips from a cup that he is
holding while sitting on the bed. T: 102. 7, HR: 140,
RR: 30, BP: 110/66. He has coarse BS with good AE.
His pulses are strong throughout. Cap refill time is
between 3-4 seconds in his hands and 2 seconds in his
feet.
Of the following, the BEST plan of management
is:
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A. BP measurement and Pulse Ox in all 4 ext.
B. Echo for coarctation of aorta
C. Empiric IV antibiotics for suspected
bacteremia
D. Inotropic therapy with dopamine for shock
E. Repetition of the perfusion exam with patient
supine and hands warmed
Clues:
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You are evaluating a 3 y/o M in the ED for fever. His
mom tells you that he had been well until yesterday,
then developed fever to 103 (orally). +clear nasal
discharge, cough and 1 episode of emesis. At time of
your evaluation he is eating chips from a cup that he
is holding while sitting on the bed. T: 102. 7, HR:
140, RR: 30, BP: 110/66. He has coarse BS with good
AE. His pulses are strong throughout. Cap refill
time is between 3-4 seconds in his hands and 2 seconds
in his feet.
Answer:
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A. BP measurement and Pulse Ox in all 4 ext.
B. Echo for coarctation of aorta
C. Empiric IV antibiotics for suspected
bacteremia
D. Inotropic therapy with dopamine for shock
E. Repetition of the perfusion exam with
patient supine and hands warmed
Explanation:
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Delayed cap refill in his hands but normal in his
feet, which can be explained by the ice chips he
is holding.
Febrile patient with decreased perfusion from
septic shock should not have a differential cap
refill in UE and LE.
All other aspects of the exam suggest good
perfusion.