Ewwww…the Boards

1. Ewwww…the Boards Jillian Parekh, MD September 8, 2009

2. Thoughts: • 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

3. Plan: • 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

4. Things to keep in mind: • You have lots of time…it is very early • 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)

5. The Basics • 1 day test (October 18th, 2010) • 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 • All questions are multiple choice (~350) • 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).

6. Getting Started • Most people use 3 months of dedicated study • Pick one main text • 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 • Make it realistic (include social events, etc) • Save time for review at the end

7. Studying methods • 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 • Discuss material with friends

8. Questions, questions, questions • Try to do about 5 years of PREP • 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)

9. Pictures • 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

10. 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:

11. What are you thinking? • A. Bacterial tracheitis • B. Bronchitis • C. Epiglottitis • D. Foreign body aspiration • E. Laryngotracheobronchitis

12. The clues: • 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.

13. Answer: • A. Bacterial tracheitis • B. Bronchitis • C. Epiglottitis • D. Foreign body aspiration • E. Laryngotracheobronchitis

14. Explanation: • Bacterial tracheitis: superinfection from viral syndrome (S.Aureus, Moraxella, nontypeable HiB). Resp distress b/c of swelling at cricoid cartilage and thick purulent secretions. • 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.

15. 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. • WHAT AGE IS THIS CHILD:

16. A. 12 months • B. 15 months • C. 18 months • D. 21 months • E. 24 months

17. Clues: • 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.

18. Answer: • A. 12 months • B. 15 months • C. 18 months • D. 21 months • E. 24 months

19. Explanation: • 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.

20. AAP guidelines: • 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:

21. 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

22. Clues: • 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.

23. Answer: • 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

24. Explanation: • 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.

25. 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:

26. A. FSGS • B. IgA nephropathy • C. Lupus nephritis • D. Membranoproliferative glomerulonephritis • E. Postinfectious Acute glomerulonephritis

27. Clues: • .A 10 y/o girl presents to the ED with 1 day h/obrown 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.

28. Answer: • A. FSGS • B. IgA nephropathy • C. Lupus nephritis • D. Membranoproliferative glomerulonephritis • E. Postinfectious Acute glomerulonephritis

29. Explanation: • 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.

30. Images: • 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:

31. A. erythema infectiosum • B. phototoxic reaction • C. polymorphous light eruption • D. scarlet fever • E. systemic lupus erythematosus

32. Clues: • 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.

33. Answer: • A. erythema infectiosum • B. phototoxic reaction • C. polymorphous light eruption • D. scarlet fever • E. systemic lupus erythematosus

34. Explanation: • 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.

35. Favorite Board Questions: • 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:

36. A. Folate • B. Iron • C. Niacin • D. Vitamin A • E. Vitamin D

37. Answer: • A. Folate • B. Iron • C. Niacin • D. Vitamin A • E. Vitamin D

38. Explanation: • 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.

39. 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:

40. 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

41. Clues: • 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.

42. Answer: • 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

43. Explanation: • 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.