Ewwww…the Ewwww…the BoardsBoards

Jillian Parekh, MDJillian Parekh, MD

September 8, 2009September 8, 2009

Thoughts:Thoughts:

The boards cover a HUGE amount of The boards cover a HUGE amount of information information

Boards come at a very stressful time Boards come at a very stressful time (soon after you graduate) when you (soon after you graduate) when you are adjusting to fellowship or a new are adjusting to fellowship or a new jobjob

The more you familiarize yourself The more you familiarize yourself with the material the betterwith the material the better

Plan:Plan:

Discuss a good study planDiscuss a good study plan Meet on a regular basis and go over Meet on a regular basis and go over

the most difficult topics (as chosen by the most difficult topics (as chosen by you)you)

Share the work amongst usShare the work amongst us Make it fun and painlessMake it fun and painless By the time you graduate, you will By the time you graduate, you will

have gone through a lot of the info have gone through a lot of the info once and have good referencesonce and have good references

Things to keep in mind:Things to keep in mind:

You have lots of time…it is very earlyYou have lots of time…it is very early But the more you familiarize yourself, the But the more you familiarize yourself, the

betterbetter You are being exposed (over exposed) to You are being exposed (over exposed) to

lots of good pediatrics during residencylots of good pediatrics during residency You are all going through it together…You are all going through it together…

use each other as supportsuse each other as supports Stick to studying methods that have Stick to studying methods that have

worked for you in the past (Step 1)worked for you in the past (Step 1)

The BasicsThe Basics 1 day test 1 day test ((October 18October 18thth, 2010, 2010))

Regsitration: Dec 1, 2009 – Feb 25, 2010 = $2,030Regsitration: Dec 1, 2009 – Feb 25, 2010 = $2,030 Late Registration: Feb 26 – May 6 =$2,335Late Registration: Feb 26 – May 6 =$2,335 To apply go to abp.orgTo apply go to abp.org Need a license to take the testNeed a license to take the test Two 3.5 hour sessionsTwo 3.5 hour sessions Test is on paper Test is on paper Long lunch break in between sessionsLong lunch break in between sessions

All questions are multiple choice (~350)All questions are multiple choice (~350) Image questions are scattered throughout testImage questions are scattered throughout test Most questions have a long clinical stemMost questions have a long clinical stem

2008 national pass rate was 77.7%2008 national pass rate was 77.7% Plan to get hotel for the night before (closest test Plan to get hotel for the night before (closest test

sites are Uniondale, LI or NJ). sites are Uniondale, LI or NJ).

Getting StartedGetting Started

Most people use 3 months of dedicated studyMost people use 3 months of dedicated study Pick one main text Pick one main text

Pick the text early on and use it during your Pick the text early on and use it during your rotationsrotations

Laughing your way Laughing your way First AidFirst Aid Use text books Use text books onlyonly as a supplement to weak as a supplement to weak

areasareas Make a scheduleMake a schedule

Make it realistic (include social events, etc)Make it realistic (include social events, etc) Save time for review at the end Save time for review at the end

Studying methodsStudying methods

Go topic by topic (chapter by Go topic by topic (chapter by chapter)chapter) Try to arrange topics according to your Try to arrange topics according to your

strengthsstrengths Don’t cluster all the heavy stuff (Endo Don’t cluster all the heavy stuff (Endo

then MSK)then MSK) Review PREP questions for that topic Review PREP questions for that topic

before moving onbefore moving on Discuss material with friendsDiscuss material with friends

Questions, questions, Questions, questions, questionsquestions

Try to do about 5 years of PREPTry to do about 5 years of PREP Remember that older years won’t be as accurateRemember that older years won’t be as accurate Leave most recent years until the end Leave most recent years until the end Study the answers, that’s where you learn the mostStudy the answers, that’s where you learn the most

Do questions in random order or by systems Do questions in random order or by systems (CDs)(CDs)

Don’t worry…you will get A LOT wrong Don’t worry…you will get A LOT wrong Oh yeah…it’s normal to get A LOT wrongOh yeah…it’s normal to get A LOT wrong Leave 2010 PREP for the end (do as a Leave 2010 PREP for the end (do as a

complete test)complete test)

PicturesPictures

There are not as many as there used to beThere are not as many as there used to be Read the question carefully, a lot of times Read the question carefully, a lot of times

you don’t even need the picture to answeryou don’t even need the picture to answer Review Zitelli whenever you have free Review Zitelli whenever you have free

timetime Flip through to look at all the picturesFlip through to look at all the pictures Great to look at it by systems with Great to look at it by systems with

corresponding review chaptercorresponding review chapter The more you look at it, the betterThe more you look at it, the better

Typical boards questions:Typical boards questions:

1. 6 year old boy presents with 2 days of 1. 6 year old boy presents with 2 days of fever and noisy breathing. No PMH. fever and noisy breathing. No PMH. Missing his last DTaP and MMR. On exam, Missing his last DTaP and MMR. On exam, he appears scared and toxic and has he appears scared and toxic and has labored respirations and a very harsh labored respirations and a very harsh cough. He is not drooling and can lie flat cough. He is not drooling and can lie flat while you examine him. T: 103.5. RR: 35. while you examine him. T: 103.5. RR: 35. HR: 168. BP: 107/68. Lungs are clear, no HR: 168. BP: 107/68. Lungs are clear, no murmur with benign abdomen.murmur with benign abdomen.

OF THE FOLLOWING THE MOST OF THE FOLLOWING THE MOST LIKELY DIAGNOSIS IS:LIKELY DIAGNOSIS IS:

What are you thinking?What are you thinking?

A. Bacterial tracheitisA. Bacterial tracheitis B. BronchitisB. Bronchitis C. Epiglottitis C. Epiglottitis D. Foreign body aspirationD. Foreign body aspiration E. Laryngotracheobronchitis E. Laryngotracheobronchitis

The clues:The clues:

1.1. 6 year6 year old boy presents with 2 days of old boy presents with 2 days of fever and noisy breathing. No PMH. fever and noisy breathing. No PMH. Missing his last DTaP and MMR. On Missing his last DTaP and MMR. On exam, he appears scared and exam, he appears scared and toxictoxic and and has labored respirations and a very has labored respirations and a very harsh coughharsh cough (brassy cough). He is (brassy cough). He is NOT drooling and CAN lie flatNOT drooling and CAN lie flat while while you examine him. T: you examine him. T: 103.5103.5. RR: 35. . RR: 35. HR: 168. BP: 107/68. HR: 168. BP: 107/68. Lungs are clearLungs are clear, , no murmur with benign abdomen.no murmur with benign abdomen.

Answer:Answer:

A. Bacterial tracheitisA. Bacterial tracheitis B. BronchitisB. Bronchitis C. Epiglottitis C. Epiglottitis D. Foreign body aspirationD. Foreign body aspiration E. Laryngotracheobronchitis E. Laryngotracheobronchitis

Explanation:Explanation: Bacterial tracheitisBacterial tracheitis: superinfection from viral : superinfection from viral

syndrome (S.Aureus, Moraxella, nontypeable HiB). syndrome (S.Aureus, Moraxella, nontypeable HiB). Resp distress b/c of swelling at cricoid cartilage Resp distress b/c of swelling at cricoid cartilage and thick purulent secretions.and thick purulent secretions. High fever, toxic with brassy coughHigh fever, toxic with brassy cough

EpiglottitisEpiglottitis: can’t lie flat, drools (dysphagia). Less : can’t lie flat, drools (dysphagia). Less common than tracheitis secondary HiB vaccine.common than tracheitis secondary HiB vaccine.

CroupCroup: not normally highly febrile/toxic, usually < : not normally highly febrile/toxic, usually < 3 y3 y

BronchitisBronchitis: dry hacking cough, non toxic, preceded : dry hacking cough, non toxic, preceded by viral URI. by viral URI.

FB aspirationFB aspiration: usually not febrile, not toxic, usually : usually not febrile, not toxic, usually will describe a 2-3 year old.will describe a 2-3 year old.

Developmental question:Developmental question:

2. You are seeing a young boy for his 2. You are seeing a young boy for his WCC. He says “mama” and “dada”, WCC. He says “mama” and “dada”, “Bye” , “Up” and “ball”. After exam, he “Bye” , “Up” and “ball”. After exam, he sits on the floor in front of his mother sits on the floor in front of his mother while playing with toy car. He points to while playing with toy car. He points to a toy he wants, and after his mom tells a toy he wants, and after his mom tells him to go get it, he brings the toy to him to go get it, he brings the toy to her. her.

WHAT AGE IS THIS CHILD:WHAT AGE IS THIS CHILD:

A. 12 monthsA. 12 months B. 15 monthsB. 15 months C. 18 monthsC. 18 months D. 21 monthsD. 21 months E. 24 monthsE. 24 months

Clues:Clues:

You are seeing a young boy for his You are seeing a young boy for his WCC. He says “WCC. He says “mama” and “dada”, mama” and “dada”, “Bye” , “Up” and “ball” = 5 words.“Bye” , “Up” and “ball” = 5 words. After exam, he After exam, he sits on the floorsits on the floor in in front of his mother while playing with front of his mother while playing with toy car. He toy car. He pointspoints to a toy he wants, to a toy he wants, and after his and after his mom tells him to go mom tells him to go get it, he brings the toy to her = get it, he brings the toy to her = follows a commandfollows a command..

Answer:Answer:

A. 12 monthsA. 12 months B. 15 monthsB. 15 months C. 18 monthsC. 18 months D. 21 monthsD. 21 months E. 24 monthsE. 24 months

Explanation:Explanation: 15 m/o have 4-6 words, follow one step commands, 15 m/o have 4-6 words, follow one step commands,

can understand instructions (without gesture), stoops can understand instructions (without gesture), stoops to floor and recovers to standing.to floor and recovers to standing.

12 m/o : pincer grasp, takes a few steps, pulls to 12 m/o : pincer grasp, takes a few steps, pulls to stand and cruises, assists with dressing, 1 word stand and cruises, assists with dressing, 1 word besides mama/dada (specific), follows single step besides mama/dada (specific), follows single step command with gestures .command with gestures .

18 m/o: Self feeds with spoon, stacks 2 cubes, 18 m/o: Self feeds with spoon, stacks 2 cubes, throws ball, walks upstairs holding on, imitates throws ball, walks upstairs holding on, imitates household chores, 10-20 words.household chores, 10-20 words.

24 m/o: Builds tower of 6 cubes, washes and dries 24 m/o: Builds tower of 6 cubes, washes and dries hands, removes clothing, kicks ball, jumps with 2 hands, removes clothing, kicks ball, jumps with 2 feet, >50 words vocab, speech is 50% intelligible by feet, >50 words vocab, speech is 50% intelligible by strangers. strangers.

AAP guidelines:AAP guidelines:

3.3. A 2 y/o boy presents with 3 days of A 2 y/o boy presents with 3 days of diarrhea and vomiting. Tolerating diarrhea and vomiting. Tolerating small amounts of fluids. small amounts of fluids. Moderately dehydrated on exam Moderately dehydrated on exam with dry mucus membranes and HR with dry mucus membranes and HR of 145.of 145.

Of the following, the BEST Of the following, the BEST management for this patient’s management for this patient’s fluid status is:fluid status is:

A. Hospitalize with IVF and a restrictive A. Hospitalize with IVF and a restrictive bland dietbland diet

B. Hospitalize with IVF and gut rest for 24 B. Hospitalize with IVF and gut rest for 24 hourshours

C. ORT at home followed by a clear liquid C. ORT at home followed by a clear liquid diet for 24 hoursdiet for 24 hours

D. ORT at home followed by a diet of D. ORT at home followed by a diet of fruits, vegetables and meatsfruits, vegetables and meats

E. ORT at home followed by a restrictive E. ORT at home followed by a restrictive bland dietbland diet

Clues:Clues:

3.3. A 2 y/o boy presents with 3 days of A 2 y/o boy presents with 3 days of diarrhea and vomiting. diarrhea and vomiting. Tolerating Tolerating small amounts of fluidssmall amounts of fluids. . ModeratelyModerately dehydrated on exam dehydrated on exam with dry mucus membranes and HR with dry mucus membranes and HR of 145.of 145.

Answer:Answer:

A. Hospitalize with IVF and a restrictive A. Hospitalize with IVF and a restrictive bland dietbland diet

B. Hospitalize with IVF and gut rest for 24 B. Hospitalize with IVF and gut rest for 24 hourshours

C. ORT at home followed by a clear liquid C. ORT at home followed by a clear liquid diet for 24 hoursdiet for 24 hours

D. ORT at home followed by a diet of D. ORT at home followed by a diet of fruits, vegetables and meatsfruits, vegetables and meats

E. ORT at home followed by a restrictive E. ORT at home followed by a restrictive bland dietbland diet

Explanation:Explanation: Mild and moderate dehydration can be managed at Mild and moderate dehydration can be managed at

home with ORT.home with ORT. ORT replaces lost electrolytes (Na, Cl, K, bicarb) and ORT replaces lost electrolytes (Na, Cl, K, bicarb) and

glucose and water. glucose and water. Monitor ongoing losses – if excessive may need NG Monitor ongoing losses – if excessive may need NG

or IV rehydration.or IV rehydration. Once adequately rehydrated, resume normal diet.Once adequately rehydrated, resume normal diet. Clear liquids and bland diet do not provide adequate Clear liquids and bland diet do not provide adequate

nutrition. nutrition. Infants should receive human milk or their usual Infants should receive human milk or their usual

formula. formula. Avoid high sugar-containing liquids because of Avoid high sugar-containing liquids because of

osmotic load.osmotic load.

Pattern recognition:Pattern recognition:

4. A 10 y/o girl presents to the ED with 4. A 10 y/o girl presents to the ED with 1 day h/o brown urine. She denies 1 day h/o brown urine. She denies dysuria, urgency, frequency and abdl dysuria, urgency, frequency and abdl pain. T: 37.1, BP: 165/97, HR: 84, pain. T: 37.1, BP: 165/97, HR: 84, RR: 20. PE: moderate periorbital RR: 20. PE: moderate periorbital edema, but otherwise normal. UA: edema, but otherwise normal. UA: moderate blood, 4+ protein. Serum moderate blood, 4+ protein. Serum C3 is low, C4 is normal.C3 is low, C4 is normal.

Of the following, the MOST likely Of the following, the MOST likely cause of the girl’s hematuria is:cause of the girl’s hematuria is:

A. FSGSA. FSGS B. IgA nephropathyB. IgA nephropathy C. Lupus nephritisC. Lupus nephritis D. Membranoproliferative D. Membranoproliferative

glomerulonephritisglomerulonephritis E. Postinfectious Acute E. Postinfectious Acute

glomerulonephritisglomerulonephritis

Clues:Clues:

.A 10 y/o girl presents to the ED with .A 10 y/o girl presents to the ED with 1 day h/o1 day h/o brown urinebrown urine. She denies . She denies dysuria, urgency, frequency and dysuria, urgency, frequency and abdl pain. T: 37.1, BP: abdl pain. T: 37.1, BP: 165/97165/97, HR: , HR: 84, RR: 20. PE: moderate 84, RR: 20. PE: moderate periorbital edemaperiorbital edema, but otherwise , but otherwise normal. UA: normal. UA: moderate blood, 4+ moderate blood, 4+ proteinprotein. Serum . Serum C3 is lowC3 is low, , C4 is C4 is normal.normal.

Answer:Answer:

A. FSGSA. FSGS B. IgA nephropathyB. IgA nephropathy C. Lupus nephritisC. Lupus nephritis D. Membranoproliferative D. Membranoproliferative

glomerulonephritisglomerulonephritis E. Postinfectious Acute E. Postinfectious Acute

glomerulonephritisglomerulonephritis

Explanation:Explanation: Strong evidence of nephritis: gross hematuria, Strong evidence of nephritis: gross hematuria,

hypertension, periorbital edema. hypertension, periorbital edema. Biggest clue: low C3 with normal C4 = PIAGNBiggest clue: low C3 with normal C4 = PIAGN PIAGN most commonly follows a strep infection. PIAGN most commonly follows a strep infection.

Most recover full renal function and C3 levels Most recover full renal function and C3 levels normalize in 6 weeks. HTN can persist for up to 3 normalize in 6 weeks. HTN can persist for up to 3 months secondary retention of salt and water. months secondary retention of salt and water. Some can progress rapidly, requiring treatment Some can progress rapidly, requiring treatment with steroids and IV cyclophosphamide or even with steroids and IV cyclophosphamide or even dialysis -- renal outcome is then guarded.dialysis -- renal outcome is then guarded.

LOW C3 and C4 = membranoproliferative GN, LOW C3 and C4 = membranoproliferative GN, lupus nephritislupus nephritis

NORMAL C3 and C4 = IgA nephropathy and FSGS.NORMAL C3 and C4 = IgA nephropathy and FSGS.

Images:Images:

5. 10 y/o girl has had a rash for 4 days without 5. 10 y/o girl has had a rash for 4 days without other symptoms. She is taking no medications. other symptoms. She is taking no medications. On PE she erythemtous cheeks and a lacy, On PE she erythemtous cheeks and a lacy, reticulated erythema involving the extremities. reticulated erythema involving the extremities.

OF THE FOLLOWING, THE MOST LIKELY OF THE FOLLOWING, THE MOST LIKELY DX IS:DX IS:

A. erythema infectiosumA. erythema infectiosum B. phototoxic reactionB. phototoxic reaction C. polymorphous light eruptionC. polymorphous light eruption D. scarlet feverD. scarlet fever E. systemic lupus erythematosusE. systemic lupus erythematosus

Clues:Clues:

10 y/o girl has had a rash for 4 days 10 y/o girl has had a rash for 4 days without other symptoms. She is without other symptoms. She is taking no medications. On PE she taking no medications. On PE she erythemtous cheekserythemtous cheeks and a and a lacy, lacy, reticulated erythemareticulated erythema involving the involving the extremities. extremities.

Answer:Answer:

A. erythema infectiosumA. erythema infectiosum B. phototoxic reactionB. phototoxic reaction C. polymorphous light eruptionC. polymorphous light eruption D. scarlet feverD. scarlet fever E. systemic lupus erythematosusE. systemic lupus erythematosus

Explanation:Explanation: Erythema infectiosum is the most common clincal Erythema infectiosum is the most common clincal

expression of parvovirus B19. Fever, myalgia, or HA expression of parvovirus B19. Fever, myalgia, or HA can precede the eruption by 7-10 days. Rash starts as can precede the eruption by 7-10 days. Rash starts as “slapped cheeks”, followed by lacy reticulated, pink “slapped cheeks”, followed by lacy reticulated, pink erythema of extremities or trunk. Less commonly, erythema of extremities or trunk. Less commonly, can see “gloves and socks” syndrome. Eruption fades can see “gloves and socks” syndrome. Eruption fades after 3-5 days, but can return with exercise/heat. after 3-5 days, but can return with exercise/heat.

Phototoxic drug reactions are not lacy/reticulated.Phototoxic drug reactions are not lacy/reticulated. Polymorphous light eruption – hypersensitivity Polymorphous light eruption – hypersensitivity

reaction to UV light, occurs 1-2 days after sun reaction to UV light, occurs 1-2 days after sun exposure. Red papules on sun exposed areas.exposure. Red papules on sun exposed areas.

Scarlet fever – fine, rough feeling erythematous Scarlet fever – fine, rough feeling erythematous papules associated with strep sx.papules associated with strep sx.

SLE – photosensitive malar rash, often involves SLE – photosensitive malar rash, often involves bridge of nose , often is scaling. bridge of nose , often is scaling.

Favorite Board Favorite Board Questions:Questions:

6. A medical student rotating in your 6. A medical student rotating in your clinic tells you about a 5 m/o he has clinic tells you about a 5 m/o he has evaluated. He reports that the evaluated. He reports that the infant is fed goat milk exclusively infant is fed goat milk exclusively and asks you if this is adequate and asks you if this is adequate nutrition at this age.nutrition at this age.

Of the following, the MOST likely Of the following, the MOST likely deficiency in this infant is of:deficiency in this infant is of:

A. FolateA. Folate B. IronB. Iron C. NiacinC. Niacin D. Vitamin AD. Vitamin A E. Vitamin DE. Vitamin D

Answer:Answer:

A. FolateA. Folate B. IronB. Iron C. NiacinC. Niacin D. Vitamin AD. Vitamin A E. Vitamin DE. Vitamin D

Explanation:Explanation:

Goat milk is used as the exclusive Goat milk is used as the exclusive source of nutrition in some countries. source of nutrition in some countries. Its fat can be digested more easily Its fat can be digested more easily than fat in cow milk. Deficient in iron, than fat in cow milk. Deficient in iron, vitamin D, and ESPECIALLY FOLATE. vitamin D, and ESPECIALLY FOLATE.

Deficiency in folate can result in Deficiency in folate can result in ineffective erythropoiesis and ineffective erythropoiesis and megaloblastic anemia.megaloblastic anemia.

Can see macrocytosis and Can see macrocytosis and hypersegmented neutrophils on CBC. hypersegmented neutrophils on CBC.

7. You are evaluating a 3 y/o M in the ED for 7. You are evaluating a 3 y/o M in the ED for fever. His mom tells you that he had been fever. His mom tells you that he had been well until yesterday, then developed fever to well until yesterday, then developed fever to 103 (orally). +clear nasal discharge, cough 103 (orally). +clear nasal discharge, cough and 1 episode of emesis. At time of your and 1 episode of emesis. At time of your evaluation he is eating chips from a cup that evaluation he is eating chips from a cup that he is holding while sitting on the bed. T: 102. he is holding while sitting on the bed. T: 102. 7, HR: 140, RR: 30, BP: 110/66. He has 7, HR: 140, RR: 30, BP: 110/66. He has coarse BS with good AE. His pulses are coarse BS with good AE. His pulses are strong throughout. Cap refill time is between strong throughout. Cap refill time is between 3-4 seconds in his hands and 2 seconds in his 3-4 seconds in his hands and 2 seconds in his feet. feet.

Of the following, the BEST plan of Of the following, the BEST plan of management is:management is:

A. BP measurement and Pulse Ox in all A. BP measurement and Pulse Ox in all 4 ext.4 ext.

B. Echo for coarctation of aortaB. Echo for coarctation of aorta C. Empiric IV antibiotics for suspected C. Empiric IV antibiotics for suspected

bacteremiabacteremia D. Inotropic therapy with dopamine for D. Inotropic therapy with dopamine for

shockshock E. Repetition of the perfusion exam E. Repetition of the perfusion exam

with patient supine and hands warmedwith patient supine and hands warmed

Clues:Clues:

You are evaluating a 3 y/o M in the ED for You are evaluating a 3 y/o M in the ED for fever. His mom tells you that he had been well fever. His mom tells you that he had been well until yesterday, then developed fever to 103 until yesterday, then developed fever to 103 (orally). +clear nasal discharge, cough and 1 (orally). +clear nasal discharge, cough and 1 episode of emesis. At time of your evaluation episode of emesis. At time of your evaluation he is he is eating chips from a cup that he is eating chips from a cup that he is holding while sitting on the bedholding while sitting on the bed. T: 102. 7, . T: 102. 7, HR: HR: 140, RR: 30, BP: 110/66140, RR: 30, BP: 110/66. He has coarse . He has coarse BS with BS with good AE. His pulses are strong good AE. His pulses are strong throughoutthroughout. Cap refill time is between 3-4 . Cap refill time is between 3-4 seconds in his hands and 2 seconds in his feet.seconds in his hands and 2 seconds in his feet.

Answer:Answer:

A. BP measurement and Pulse Ox in all 4 A. BP measurement and Pulse Ox in all 4 ext.ext.

B. Echo for coarctation of aortaB. Echo for coarctation of aorta C. Empiric IV antibiotics for suspected C. Empiric IV antibiotics for suspected

bacteremiabacteremia D. Inotropic therapy with dopamine for D. Inotropic therapy with dopamine for

shockshock E. Repetition of the perfusion exam E. Repetition of the perfusion exam

with patient supine and hands warmedwith patient supine and hands warmed

Explanation:Explanation:

Delayed cap refill in his hands but Delayed cap refill in his hands but normal in his feet, which can be normal in his feet, which can be explained by the ice chips he is holding.explained by the ice chips he is holding.

Febrile patient with decreased Febrile patient with decreased perfusion from septic shock should not perfusion from septic shock should not have a differential cap refill in UE and have a differential cap refill in UE and LE. LE.

All other aspects of the exam suggest All other aspects of the exam suggest good perfusion.good perfusion.