2016 Pediatric Board Review Books – A Sneak Peek
The 2016 Pediatric Board Review PREVIEW Is Here!
Unlike other board review courses, the PBR's Core Study Guide gets corrected and updated EVERY year. Many of the corrections and clarifications of the current 2015 edition are are made available to the PBR community here, and they will provide a sneak peak into the 2016 edition as well.
In this article, you will:
- Get a preview of the most EFFICIENT 2016 pediatric board review course available
- Get a great review of several excellent and high-yield topics
- Get a FREE MP3 Audio Chapter from PBR
- Get 50 FREE High-Yield Images from PBR
- Get a FREE Test-Taking Strategies Video Training Session
- Get the opportunity to PREORDER the 2016 edition books for 50% off of the value of the Ultimate Bundle Pack or the lifetime package called “PBR FOR LIFE!”
A FEW WORDS OF THANKS TO THE PBR COMMUNITY
Every year I like to go through all PBR error submission and send corrections to PBR members before the initial certification exam. It’s an EXTREMELY time consuming task (takes several full days), but I believe it’s worth it.
Although the information in this corrections area SHOULD NOT make or break your test-experience if you have followed the PBR Efficiency Blueprint, several test-takers have previously said that they enjoyed reading the clarifications, and that the reviews in the guide even helped them correctly answer several questions that came up on the exam.
Thank you to EVERYONE who submitted spelling errors, typographical errors, corrections or requests clarifications from within the PBR by visiting the ERROR page. Also,thanks to EVERYONE who submitted broken links from within the PBR and the PBR Picture Atlas by visiting the BAD LINK page.
Also, thanks for all of the participation in PBR's private members' only forum, called the PBR Discord Community I kind of “stalk” the group and if I see something comes up that might warrant a correction or a clarification in the PBR, I set it aside for this time of year to review.
An absolutely MASSIVE THANK YOU TO DR. MIKE BLYTH! Mike is a PBR alum, he’s PBR’s editor, and he’d done a great job of helping us streamline several systems in the world of PBR to make YOUR experience better!
THANK YOU!
ARE YOU NERVOUS BECAUSE THERE ARE CORRECTIONS?
ALL study guides have errors!
I’m simply the only author who is crazy enough, and passionate enough, to take on something like this prior the boards every year so that you can rest EASY. And instead of just giving you a one page errata sheet based on error submissions, we try to go much deeper in our explanations and we also SEEK OUT areas of improvement to share with you.
For some people, though, the idea that the PBR has errors can be anxiety provoking.
If you’re one of those members, please keep in mind that there are approximately 2000 topics within the PBR, and each topic has MANY salient points associated with it. There are probably over 10,000 individual pieces of information in the PBR. Therefore, the number of corrections below is relatively TINY.
So you should rest easy knowing that you’re in good hands with the information that you’ve been using up until now, and that there is MORE THAN ENOUGH excellent content within your PBR to get you your PASS!
WHAT ABOUT IMAGE CORRECTIONS?
We have a very innovative system that allows you to view phenomenal high-yield images across the web. We have approximately 400 image links in the PBR, but they lead to images that are not owned by PBR. That means that any given time, an unrelated PBR website that houses a high-yield image might be down. When you notify us of this, it’s a HUGE help and we can quickly replace the image link with a new, comparable image.
In the past we would send out replacement image links for the ones that were broken throughout the web. Because of our new systems, all of the image link corrections now happen on the BACKEND.
We just did a huge search and replace of the image links, so 97% – 99% of the links in the PBR and the online picture atlas should be working without any issues!
If you do find that there’s an issue, please notify us immediately by visiting our “bad link” page.
As a reminder, the EASIEST way to go through all of these images is by using the online picture atlas created by Team PBR (called the Virtual Atlas of Pediatric Pictures). The VAPP gives you a SUPER fast and high-yield review of board-relevant images.
You can watch the video below to see how it works:
www.PediatricsBoardReview.com/vapp
GET 50 FREE IMAGES BY CLICKING THE IMAGE BELOW!
FREQUENTLY ASKED QUESTIONS
“Is this a complete list of everything that’s changing for the 2016 Pediatrics Board Review course?”
NO! The new edition will have MORE additions and modifications. What’s included in this Corrections & Clarifications Guide is:
- A set of absolute notifications because they were true errors that we verified.
- Several clarifications and discussion around confusing stuff.
For the 2016 pediatric board review books, online versions (and possibly iPhone/iPad versions) we're strongly considering adding an entire chapter on things like quality improvement and ethics.
“If I have the old book… Should I keep that one or get the new one?”
If your exam is at least 3 months away, then you should seriously consider getting the new edition. The edition you have DOES HAVE enough information in it to help you pass the initial certification exam or the recertification exam, BUT we tend to add new information, and even new chapters that you are definitely going to want.
Here are the 3 main reasons to get the new edition if you still have an old one:
- SAVE AND MAXIMIZE YOUR TIME – DON'T “MESS AROUND” WITH CORRECTIONS TO SAVE A FEW BUCKS
- If you have an older version of the book and taking the boards several months from now, then this is NOT the time to be messing around with a Corrections & Clarifications guide and trying to cross check everything against your older version of the PBR. Please understand that your time is PRECIOUS and needs to be spent efficiently and effectively. Plus, there is ALWAYS new content in the new editions.
- Start with a fresh book, transfer any notes/drawings from your previous hardcopy to the new edition as you read through it the first time and then use the new one as your bible!
- COST
- By cost, I mean money and opportunity cost. The cost of a new book is minimal compared to the hard financial costs and opportunity cost of FAILING the boards. The financial cost of FAILING includes over $2000 just to sign up for the new boards, plus the cost of taking time off of work to study again next year (THOUSANDS of dollars of lost income) and opportunity cost related to stress and time away from loved ones.
- If you have some OTHER reason to keep studying from an older edition, so be it… but if it’s due to financial concerns, that’s kinda dumb. Sorry… this is the one place in this document where I just have to be blunt. I have such a passion for efficiency and QUALITY USE OF TIME that it really pains me to hear about docs that are trying to go back and forth between the corrections guide and their old guide in order to save a few bucks.
- REFERENCES TO PBR IN THE CREW!
- The PBR Discord Community Comes alive with discussion as the boards approach. Many PBR alumni have said that the Facebook CREW! heavily contributed to their success on the boards. When your peers in “The CREW” are referring to certain topics on certain pages, do you really want to (again) waste your precious time fumbling around and trying to find the topic they’re referring to?
- UPGRADED FORMATS: Every edition is MUCH better than the previous.
- Corrections
- Clarifications
- New images
- NEW, TIME-SAVING Innovations. For example, our links used to be EXTREMELY long. Now we have a system that turns http://upload.wikimedia.org/wikipedia/commons/4/45/Aphthous_ulcer.jpg into something easy like pbrlinks.com/aphthous1. HOW COOL IS THAT! Try typing out the 2 different links and see HOW FAST you get to review images using the new PBR linkJ – these things get me SO GEEKED!
- NEW CORRECTIONS: There WILL be other corrections that will make their way into the new edition. MANY of the corrections below were included in this guide because of help from the PBR community, and many were done on my own. But there are more that need further investigation before the next edition is released.
- NEW CLARIFICATIONS: Again, there was ACTIVE discussion within the members’ only PBR Facebook CREW! about board review topics that I THOUGHT were explained well within the PBR. That discussion leads me to believe that I can be EVEN MORE clear in future editions. There will be a lot of clarifying and updating of topics prior to the release of the next edition.
- NEW MATERIAL: The 2016 Edition of the PBR will likely include new chapters focused on medical ethics, quality improvement and patient safety issues that have started to appear on the boards.
DISCLAIMERS/WARNINGS – READ THIS BEFORE YOU GET STARTED
- DEAR PBR MEMBERS: You absolutely DO NOT need to review this in order to pass the initial ABP EXAM or the recertification exam. There are over 10,000 learning points in the PBR. The corrections and clarifications below will not make or break you.
- The page numbers in this guide refer to the 2015 Editions of the Pediatrics Board Review books (cover shown below).
- Reminder… I LOVE being told I’m wrong (sort of), but the best place to submit error submissions, corrections, requests for clarifications, etc. is here: www.pediatricsboardreview.com/ERROR
- DEAR NON-PBR MEMBERS: The PBR Discord Community is a private, members-only area for anyone who has signed up for a qualifying resource. YOUR REQUESTS TO JOIN WILL BE REJECTED if you have only signed up to get free info from PBR (free GI & DERM study guides, free emails about new PBR web article, free Q&A discounts, free MP3, etc). We cross-check all requests to join “The CREW” before clicking the APPROVE button. This is done in order to keep it a spam-free, private and intimate area.
To get access to the Discord Community, you can join the PBR Online Bundle Pack, or you can join one of these more comprehensive memberships with some pretty impressive discounts (new members only and this offer will end as soon as we finalize our 2016 edition).
PBR is now taking PREORDERS for the 2016 Edition of the PBR at 50% OFF the Value
Our goal is to release the 6th Edition of the PBR by approximately mid-December.
- Lock in current pricing for either of these memberships:
- Ultimate Bundle Pack
- PBR FOR LIFE!
- Get FREE shipping. Please note that if the links below lead to our standard catalog area, then the preorder offer is no longer available.
- Get immediate online access to the online and mobile versions of the PBR Core Study Guide and Q&A Book!
- Get access now to the PBR Discord Community
ULTIMATE BUNDLE PACK (PREORDER)
PBR’s Hardcopy Core Study Guide ($175)
PBR’s Hardcopy Q&A Book ($25)
PBR’s Online Core Study Guide ($75)
PBR’s Online Q&A Book ($25)
1 Full Year of Online Access
First-Time Money Back PASS Guarantee
VALUE = $300 + $15 S&H = $315
$315>>$160 + FREE Shipping
That’s 50% Off Of The Entire Value
DISCOUNT LINK: www.PediatricsBoardReview.com/preorder-UBP
(NEW Orders Only)
===
PBR FOR LIFE! (PREORDER)
PBR’s Hardcopy Core Study Guide ($175)
PBR’s Hardcopy Q&A Book ($25)
PBR’s Online Core Study Guide ($75)
PBR’s Online Q&A Book ($25)
Online Virtual Atlas of Pediatric Pictures ($147)
15+ Hours of Test-Taking Strategies Webinar Bonus Archives ($200)
LIFETIME Online Access
First-Time Money Back PASS Guarantee
50% Off of All Future Hardcopy Editions of the PBR
VALUE = $647 + LIFETIME ONLINE ACCESS = $647+++
$647>>$260 + FREE Shipping
That’s More Than 60% Off Of The Entire Value
DISCOUNT LINK: www.PediatricsBoardReview.com/preorder-PFL
(NEW Orders Only)
NOW LETS GET STARTED! WE'LL START WITH THE 2015 CORRECTIONS FIRST!
This first section is going to cover TRUE ERRORS that were in the PBR. We'll cover the CLARIFICATIONS later.
PBR had many spelling errors
Thanks for bringing these to our attention when you find them! Believe it or not, we’ve been able to eliminate at least 95% of these compared with previous editions due in part to your assistance. For celebrity names, we kept some misspellings on purpose.
PEDIATRIC ADOLESCENT MEDICINE
PBR says that a biopsy is part of the workup for a suspicious scrotal mass. This is incorrect.
> You’re right! The book has been corrected. Next edition version is below…
TESTICULAR CANCER
Testicular cancer results in a painless scrotal mass. When doing the cancer workup, get HCG and AFP levels. If either is high, get a scrotal ultrasound and a CT of the chest/abdomen/pelvis for staging. A biopsy should not be preformed due to the risk of tumor seeding. Treatment will include at least an orchiectomy.
PEDIATRIC EMERGENCY MEDICINE & TOXICOLOGY
For burns, DRY dressing is recommended instead of wet dressing to avoid hypothermia.
> You’re right! The main message for major burns should be to use dry dressings to help control heat loss. For small burns with little risk of hypothermia, wet dressings may be preferred for better comfort.
PEDIATRIC OB/GYN
PBR says that 4 mg of folic acid per day is recommended for all women trying to conceive. I think the standard recommendation is 0.4 mg/day except for women at risk.
> You’re right! The book has been changed. Next edition version is below…
FOLIC ACID
All women of childbearing age should consume 0.4 mg (400 mcg) of folic acid per day. Women planning to become pregnant and who have already had a child with a neural tube defect should consume 4 mg of folic acid per day.
PEDIATRIC OPHTHALMOLOGY
The book says that chalazions resolve on their own and that warm compresses do not help. Actually, warm compresses are recommended and sometimes chalazions need treatment when they do not resolve.
> Correct! Particularly for larger lesions. Although most will resolve on their own, stubborn ones may need treatment by an ophthalmologist (e.g. with I&D, steroid injection or drops). Next edition version is below…
CHALAZION
A chalazion is a much slower-growing, painless lesion that results from inflammation of the meibomian gland. There can be erythema as well, but it is much less painful. It resolves on its own, and warm compresses do not help.
PEARL: Ophthalmology should be involved if it is chronic or interferes with a patient’s vision.
The book uses the term “presbyopia” for farsightedness but the correct term is hyperopia.
You’re correct! “Presbyopia” means far-sightedness due to aging, while the general term should be hyperopia or hypermetropia. The book has been changed.
HYPEROPIA
Hyperopia (hypermetropia) means a child is farsighted. As an FYI, “presbyopia” also means farsighted, but the term is typically reserved for farsightedness related to aging.
PEDIATRIC INFECTIOUS DISEASES
PBR states that the most common organisms in mastoiditis are the “HMS” bugs of Haemophilus influenza, Moraxella catarrhalis, and Streptococcus pneumoniae. Most recent PREP 2014 answers states that “the bacteria most likely to cause mastoiditis in children include Streptococcus pyogenes, Streptococcus pneumonia, and Staph aureus.
> Correct! Things have changed and the book has been updated to show those three. New version…
MASTOIDITIS
Look for pain, swelling, and redness in the posterior auricular area as an indication of mastoiditis. The most commonly isolated organisms in acute mastoiditis are Strep pneumoniae, Strep pyogenes, and Staph aureus. Diagnose by doing a tympanocentesis, sending pus for culture, and getting a CT scan. Treat with IV antibiotics and surgical debridement.
PEDIATRIC VACCINES
Under Pregnancy and Immunization, the PBR says that DTaP is recommended during pregnancy. This should be Tdap, not DTaP.
> Correct! The book has been updated.
Page 303 says that the first rotavirus vaccine dose cannot be given at 15 weeks or older, while on page 307 the age limit is 12 weeks. Which is correct?
The correct answer is that the first dose should not be given to infants who are 15 weeks or older (14 weeks and 6 days is the maximum age for the first dose).
PEDIATRIC FLUIDS AND ELECTROLYTES
The paragraph on cerebral salt wasting is confusing. PBR says that there is hyponatremia and elevated urine sodium but that the serum osmolality is higher than the urine osmolality.
> Good catch. Perhaps the most important point in the paragraph is that cerebral salt wasting is a complicated, low-yield topic that you can safely ignore. However, the main features of the condition are
- low serum sodium and osmolality
- inappropriately high urine sodium and osmolality, and
- evidence of hypovolemia (e.g. low blood pressure, poor skin turgor)
It is the hypovolemia that distinguishes CSW from SIADH. The book has been changed to read as follows…
* CEREBRAL SALT WASTING: This is low-yield and complicated; it is controversial whether it even exists. The blood and urine electrolyte picture is the same as in SIADH with low serum sodium and osmolality and inappropriately high urine sodium and osmolality. The important difference between CSW and SIADH is that in CSW there is volume depletion. Look for hyponatremia, high urine sodium and osmolality, and clinical evidence of hyponatremia such as hypotension, high hematocrit, and poor skin turgor.
PEDIATRIC STATISTICS CHAPTER
I think the calculation of incidence on page 349 is incorrect.
> True. The incidence is the number of new cases occurring over a given time period and is reported as cases per person-year. In the example, there are 30 new cases in a population of 2000 people over two years. That makes 30 cases per 4000 person-years, or 7.5 cases per 1000 person years.
PEDIATRIC NEUROLOGY
I don’t think the definitions of Erb’s and Klumpke’s palsies are correct. My understanding is that Erb’s palsy is an injury to C5-C6, while Klumpke’s is to C7-T1.
> For this one, I’d ask that you avoid getting too lost in the details of terminology since definitions vary and these injuries are not simply one or the other. The important points are that Erb’s palsy is an upper brachial plexus injury and involves paralysis of the proximal muscles of the upper extremity, while Klumpke’s palsy is due to a lower injury and affects more distal muscles (hand and wrist).
Erb’s palsy= C5-C6 and sometimes C7. Uncommonly, it can be accompanied by unilateral diaphragmatic paralysis (C3-C5; PBR incorrectly implies that this is always the case). The arm is limp, adducted, and internally rotated. If C7 is affected, there will be a “waiter’s tip” hand.
Klumpke’s palsy = C8-T1and often includes Horner’s syndrome. The arm and shoulder are in normal position but the wrist and hand are flexed.
Image showing the two side-by-side: http://pbrlinks.com/ERBKLUMPKE
Here’s the updated section from PBR:
ERB’S PALSY AND KLUMPKE PALSY
Erb’s Palsy and Klumpke Palsy are both associated with birth trauma, BREECH delivery, caesarian sections, clavicle fractures and LGA births.
PEARLS: Images of the arm/hand deformities MAY look the same. The only way to discern which palsy the child has is to evaluate the patient for specific neurologic limitations. If the baby is able to grasp, it is an ERB PALSY. If you note a claw hand deformity in a patient able to flex at the elbow, it is a KLUMPKE PALSY.
* ERB PALSY (AKA ERB’S PALSY): Brachial plexus injury at C5–6 or –7, resulting in paralysis of the UPPER ARM. There is a “waiter’s tip” configuration if C7 is involved. There is UNILATERAL DIAPHRAGMATIC PARALYSIS in about 5% of cases.
- IMAGE: http
- PEARLS: The grasp and extension of the hand are INTACT. Respiratory distress can result due to phrenic nerve injury (look for a broken clavicle) resulting in unilateral diaphragmatic paralysis. It is often associated with LGA babies, breech deliveries, and C-sections.
- MNEMONIC: Imagine a WAITER named “ERB” subtly asking for a tip. He CAN grasp the money you give to him.
* KLUMPKE PALSY: Brachial plexus injury, but lower (C8-T1). This affects the LOWER arm and hand. It carries a worse prognosis because the nerves are typically torn. It results in a CLAW HAND deformity in which there is an INABILITY TO GRASP. Horner’s syndrome (below) is usually present. Less common than Erb’s palsy.
- MNEMONIC: The hand is stuck in a configuration in which the hand has a KLUMP OF AIR in it.
- IMAGE: http shows Erb’s and Klumpke’s together.
PEDIATRIC ORTHOPEDICS
PBR states that most common ankle sprain injury is to the lateral aspect of the talofibular ligament. The correct information is that the anterior talofibular ligament is most often injured.
> Thanks! We’ve updated the book to…
* ANKLE SPRAINS: Most are due to inversion and resulting injury to the ANTERIOR TALOFIBULAR LIGAMENT (ATFL).
I think the treatment for joint hypermobility should be strengthening, not stretching as is stated in PBR.
> YES AND NO! But let’s go with your thoughts because after digging into recommendations about this, it’s not clear. That means you will NOT be tested on whether the treatment is strengthening or stretching. However, there does seem to be a consensus that strengthening is important. Stretching may also be part of therapy, but probably not stretching beyond the normal joint position. The book is being changed to:
JOINT HYPERMOBILITY
A child with joint hypermobility might present with a history of “loose joints.” It sounds good, but these children are actually more prone to getting injured with sprains. Treatment includes pain management and physical therapy.
MNEMONIC/PEARL: They’ll talk about loose JOINTS, not someone being extremely flexible.
PEDIATRIC RHEUMATOLOGY
PBR says that ANA and rheumatoid factor (RF) make the diagnosis of oligoarticular JIA more likely. In fact, RF is not common in oligoarticular disease.
> You’re right! The book has been changed.
*OLIGOARTICULAR JIA (OLIGOARTHRITIS AKA PAUCIARTICULAR JUVENILE IDIOPATHIC ARTHRITIS): This refers to JRA that affects 4 OR FEWER JOINTS, and is the more common type of JRA (>50%). ANA is often present but other markers such as RF are usually negative. It’s more common in younger girls and is associated with chronic uveitis. Since visual complaints may be absent, patients need to have regular eye exams. Boys have a better prognosis.
PEDIATRIC QUESTION & ANSWER BOOK
The answer to #13 seems to read correctly, but I think the wrong letter was selected as the answer.
> You’re right! I actually didn’t like the vignette OR the last two answer choices because someon could make the argument that either one of them could be correct. SO, I modified the vignette and I updated the answer. The NEW Q&A for #13 is below.
- A 5-month-old male presents for a well-child visit. The child’s brother had developmental dysplasia of the hip. The patient has no extra folds and both the Barlow and Ortolani maneuvers are negative. The mother asks if this child needs to have any special tests done. What is the next best step in management?
- Ultrasound of the hips.
- Hip X-rays.
- Reassure the mother that this child has a normal exam, but recommend follow up with an orthopedist for further evaluation and risk stratification.
- Inform the mother that her son has a normal exam and he does not need any imaging studies.
- The answer is D, “Inform the mother that her son has a normal exam and he does not need any imaging studies.” DEVELOPMENTAL DYSPLASIA OF THE HIP – Infants with developmental dysplasia of the hip (DDH) may be noted to have a leg-length discrepancy, extra creases at the thigh, “clunks” or “clicks” on exam. A majority of newborn “clunks” resolve by 2 weeks of age. So do NOT obtain any imaging at the time of birth. ALL patients with an unequivocal Barlow or Ortolani maneuver (meaning there’s no question in your mind on exam) should be referred to an orthopedist for evaluation. There is only one category of infants in which the American Academy of Pediatrics guidelines REQUIRES further imaging. It’s the category of girls with a breech presentation. There are two categories in which imaging, or referral to an orthopedist, seems strongly recommended. These include boys with a breech presentation and girls with a history of an affected first-degree relative. For the purposes of the exam, you should order imaging for any child that fits into one of these three categories or has a positive exam. Everyone else can be followed up with serial exams if the exam is negative. That means a BOY with a history of an affected first-degree relative is treated the same as a boy without a history of an affected first-degree relative. One equivocal exam is okay but if it is equivocal on repeat examination at 2 weeks, then refer to orthopedics or obtain imaging. For children under 4 months of age, ultrasound should be used. After 4 months of age, X hip-rays should be used. Treatment of DDH requires a Pavlik harness.
- PEARL: The guidelines seem to suggest that referral to an orthopedist is the preferred option when there is concern. On the exam this may not be an option since the ABP likes for YOU to make such decisions instead of leaning on consultants. In that case, you will need to decide on the modality of imaging. The age cut-off for ultrasounds is 4 months, NOT 6 months. NEVER image before 2 weeks of age. For a child with no clinical signs of DDH on exam but with a NEED for evaluation based on high risk factors, you can ultrasound at 6 weeks or obtain radiographs at 4 months of age. When it comes to the Barlow and Ortolani signs, if EITHER of them are positive, refer or send for imaging (after 2 weeks of age)! ALL children should be “screened” periodically at the well-child visits by EXAM! Meaning, if you’re asked if you should “screen” a child for DDH at the 2-month visit, the answer is always going to be YES. Lastly, if you encounter an asymptomatic child that was supposed to get imaging (e.g., breech girl) but never did, and the patient is now 5 or 6 months old, GET IMAGING even if the exam is normal!
- IMAGE: http://pbrlinks.com/DDH1
- IMAGE: http://pbrlinks.com/DDH2
STRONG WORK EVERYONE AND THANK YOU SO MUCH FOR CALLING ME OUT!
NOW LET’S GO OVER THE CLARIFICATION REQUESTS!
This section is going to cover CLARIFICATION REQUESTS, or stuff that I felt might warrant a more clear explanation from within PBR.
“Do you think we should study tympanograms?”
> I don’t usually like to answer these types of questions in this guide, BUT… I think my answer could help a lot of you from straying too far off of the PROVEN PBR PATH right now.
It’s possible you’ll get ONE question on this. That’s too low yield for you to pursue studying now. Focus on the rest of PBR, which covers ALL of the very LOW HANGING AND HIGH-YIELD FRUIT!… AND SO MUCH MORE!
“I've seen a couple of practice questions about XXXXXXX and about XXXXXXX. I think you should consider maybe including these topics in the PBR.”
Thanks so much for ALL of your submissions. My answer to this question is a resounding “NO.” Trust me when I say that it’s VERY realistic/possible to pass the exam with a first edition of the PBR from 2011. PBR will NEVER be a mini-Nelsons. Meaning, it’ll NEVER be a book where you can turn to for every pediatric diagnosis known to man. It’s not meant to help you be the most well-rounded and knowledgeable pediatrician in the world. It is DEFINITELY meant to give you MORE than what you need to pass the boards.
Know it inside and out… and ignore everything else… because there’s ALWAYS more that you could possibly chase down the rabbit hole… or the BLACK HOLE of Google Search.
PEDIATRIC GASTROENTEROLOGY
The book’s explanation of hepatitis B serology is confusing when it says, “If [anti-HBc] test is positive and IgG is also positive, this represents a PAST INFECTION (not immunization). If only IgG is positive, that represents prior immunization.”
> Yup… It was confusing and has been reworded to…
If the IgG antibodies to core and surface antigens are both positive, this represents a PAST INFECTION (not immunization). If only anti-HBs is positive, that represents prior immunization.
In Wilson’s disease, is the serum copper level high or low? I thought it was high.
Understandably a confusing topic…
Ceruloplasmin is low and copper is not properly incorporated into ceruloplasmin, so the serum copper serum level is low, but the tissue copper level is high.
PYLORI TREATMENT options were questioned.
> Everything looks okay in the PBR. PPI + Amox + Metro is acceptable since some kids don’t tolerate Clarithro. Another option is a PPI + Clarithro + Metro.
HELICOBACTER PYLORI
* PEPTIC ULCER DISEASE (AKA H. pylori induced PUD)
If a patient is diagnosed with an ulcer of any type that is found to be positive for H. pylori, treatment will require a proton pump inhibitor (PPI) and antibiotics. Possible regimens include:
- PPI + Amoxicillin + Clarithromycin
- PPI + Amoxicillin + Metronidazole (good if the patient can’t tolerate clarithromycin)
- PPI + Clarithromycin + Metronidazole (good if the patient is allergic to penicillin)
* NODULAR GASTRITIS: The most common etiology is H. pylori. An EGD with biopsy (samples sent for pathology) is the gold standard for diagnosis. This can also be found in Crohn’s disease.
* CAMPYLOBACTER-LIKE ORGANISM TEST (AKA CLO test or Rapid Urease Test): Just know that this can be used at the time of an EGD to help diagnose. It’s faster and cheaper than sending a biopsy specimen to pathology, but it is not as specific as an EGD with biopsy.
* UREASE BREATH TEST: This is a noninvasive means to attempt diagnosis of Helicobacter pylori.
PEDIATRIC ENDOCRINOLOGY
In testicular feminization, why are breasts present given that there are no ovaries to produce estrogen?
> The defect in the androgen receptor gene prevents the development of male external genitalia. Even though no ovaries are present, there are pathways through which testosterone is converted to estrogen. Therefore, breasts do develop under the influence of that estrogen.
PEDIATRIC ALLERGY & IMMUNOLOGY
I’m not sure what the paragraph on penicillin desensitization is saying. “Desensitize patients with a penicillin allergy if they have SYPHILIS IN PREGNANCY or if you are presented with a CYSTIC FIBROSIS (CF) patient with resistant Pseudomonas.”
> Other antibiotics can usually be found for someone who is allergic to penicillin. However, there are certain cases, such as syphilis in pregnancy, where penicillin is the ideal drug. In such cases, a patient can be rapidly desensitized to penicillin by receiving graduated doses.
Clarified paragraph:
PENICILLIN (PCN) ALLERGY
In most cases, alternative antibiotics can be used when patients are allergic to penicillin. In some cases, however, such as syphilis in pregnancy, penicillin is the best treatment. Desensitize patients with a penicillin allergy if they have SYPHILIS IN PREGNANCY or if you are presented with a CYSTIC FIBROSIS (CF) patient with resistant Pseudomonas (needing an anti-pseudomonal penicillin such as ticarcillin).
The section in B-cell deficiencies says, “Because of problems with antibody production, you will NOT FIND THE EXPECTED TITERS for bacteria we typically immunize against, including Tetanus, Diphtheria, and Streptococcus (AKA pneumococcus).” Can you clarify how this helps diagnose B-cell deficiencies?
Children immunized with these antigens should produce the corresponding antibodies if they have normal B-cell function. If the titers arelow or undetectable, then a B-cell deficiency is likely!
Is desensitization recommended for children who react to a bee sting with urticaria?
> Opinions vary about the indications for venom immunotherapy in children with systemic, but not severe, reactions such as urticaria (so you’ll not likely be tested on the issue). It’s probably enough to know that immunotherapy is not generally required because, unlike adults, these children have a low probability of having anaphylactic reactions in the future. The PBR has been updated:
URTICARIA(HIVES)
If urticaria is due to a bee sting, consider giving EPINEPHRINE and refer the patient to an allergist. If there is a life-threatening reaction (anaphylaxis, airway compromise), the patient will need venom immunotherapy. Pre-adolescents who react only with urticaria or angioedema (but not airway compromise) rarely have severe reactions in the future, so VIP is probably not indicated.
PEDIATRIC CARDIOLOGY
Page 122 first says Strep viridans is the most common cause of endocarditis in children. The next page says Staph aureus is the most common etiology of bacterial endocarditis in children. If the distinction is important, which is right?
> These are two different issues. Strep viridans is the most common cause of all endocarditis in children. However, when it comes to acute bacterial endocarditis, Staph is the most common cause. Note the different presentations described in the book.
PEDIATRIC EMERGENCY MEDICINE & TOXICOLOGY
The book describes what to do for ingested coins, which are the most commonly ingested foreign bodies. What about sharp objects such as needles?
> This was a fun question to talk through in the Online Video Course. We added a new paragraph to the PBR…
Sharp objects noted to be in the stomach or proximal duodenum should be removed with a flexible and the scope immediately. Once the object is beyond the reach of a flexible endoscope, SURGICAL removal is indicated for SYMPTOMS (pain, vomiting, fever or evidence of bleeding) or if the object FAILS TO PROGRESS on imaging over 3 consecutive days.
PEDIATRIC GENETICS & INHERITED DISEASES
I think Angelman Syndrome should be maternal imprinting, because the maternal gene on chromosome 15 is missing, but PBR says paternal imprinting.
>The book is right on this one but this is a fairly tricky topic. Know that imprinting is a normal process and means that the gene from one parent is inactivated while the gene from the other parent is active. Maternal imprinting means that in the child, the copy on the maternal gene is inactive. Remember, this is normal and doesn’t cause disease, because only one copy is supposed to be active.
The problem arises when the other, non-imprinted active gene is defective. Then you have one gene that is silenced (imprinted) and another that is defective, so zero functional genes. Angelman syndrome involves a paternally imprinted gene. The father’s gene is inactive and a maternal gene is defective. The reverse is true in Prader-Willi.
What’s the major valve problem in Marfan’s.Aortic or Mitral problem?
> Can actually have AR, MR, or MVP. Focus on the MVP for the boards.
(DOUBLE TAKE) MARFAN’S SYNDROME (AKA MARFANS SYNDROME)
Classic features of Marfan’s Syndrome (AKA Marfans Syndrome) include tall stature with long and thin upper extremities, long fingers, a pectus deformity, joint flexibility/hypermobility, and possible cardiac problems. Cardiac problems may include mitralvalve prolapse (MVP), aortic dissection, and mitral or aortic regurgitation. Patients may have a high arched palate and a speech disorder, but do NOT have cognitive deficits. Patients are also at risk for esophageal perforation.
* PEARLS: Patients can have subluxation of the lens, which may also be seen in Ehlers Danlos and homocysteinuria. If they mention SUPERIOR subluxation of the lens, pick Marfan’s. Any patient with Marfan’s should not be cleared for sports participation until they have had an echocardiogram and an evaluation by a cardiologist. If they mention “arm span greater than height,” you’re done.
* IMAGE: http://pbrlinks.com/MARFANS1 – Please do not get distracted by the reading. Look at the images and move on.
* IMAGE: http://pbrlinks.com/MARFANS2
* MNEMONIC: http://pbrlinks.com/MARFANS3 – Michael Phelps won several gold medals. Isn’t that just like winning the Most Valuable Player (MVP = Mitral Valve Prolapse)?
“Is retinitis pigmentosa AD, AR, X-linked?”
> Honestly… b/c it’s so many things, it doesn’t matter b/c you won’t be tested on it. In the book it’s listed under “other autosomal dominant disorders” b/c regardless of the proportion of identified mutations, most of the clinically relevant cases tend to be AD… but again, even if I’m wrong… it doesn’t matter. Just look for a family history.
* RETINITIS PIGMENTOSA: Retinitis pigmentosa is a retinal dystrophy that eventually leads to blindness.
PEARL: There are multiple inheritance patterns (autosomal dominant, autosomal recessive, X-linked) so you will not be asked to identify a single inheritance pattern. BUT, look for a family history.
PEDIATRIC VITAMIN & NUTRITIONAL DISORDERS
“Which Vitamin D to check? How to treat?”
> If GIVEN a history of renal disease, 1,25 Vit D. If NOT or if asked for a general screen, then 25-Vit D. Treat with the active form of 1,25 Vit D.
VITAMIN D & ITS EVALUATION
The liver sends 25-Vitamin D to the kidneys where it gets hydroxylated to 1,25 Vitamin D (the active form). If looking for a nutritional deficiency, obtain a 25-Vitamin D level. SUPPLEMENT with 1,25 Vitamin D (the ACTIVE form). Typically, 25-Vit D is the first one you should check (especially if they ask for a screen). IF you are given a history of renal disease, check for 1,25 Vitamin D.
MNEMONIC: Where is the Vitamin D produced that carries 2 numbers with it (1 and 25)? TWO organs = TWO kidneys = TWO numbers (1 and 25)!
MNEMONIC: Which one is the active form? Think of it this way… if you ingest a calcium containing food in its natural form, it will first go to the gut, then the liver, then the blood, then finally the kidneys! So keeping the above mnemonic in mind, it’s the Vitamin D with TWO numbers!
PEARLS: Here are some ways Vitamin D deficiency could present
* African-American (AA) breastfed child whose mom is not on Vitamin D supplementation
* African-American (AA) breastfed child whose mom is not getting enough sunlight
* Child with symptoms consistent with malabsorption
* Child with a history of epilepsy who is on anti-seizure medications
PEDIATRIC INFECTIOUS DISEASES
“So what is the consensus on pertussis prophylaxis after 6 wks of age? The PBR says EES, but PREP says azithromycin. What is your take on this?”
> Even the Red Book doesn’t really seem to have a preference, so I don’t think they could give you both options. For less than 1 month of age, definitely Azithro due to concerns for pyloric stenosis.
I stand by the info below.
BORDETELLA PERTUSSIS (aka WHOOPING COUGH)
Bordetella pertussis (aka whooping cough) patients are described as having bursts, or “paroxysms,” of coughing. They cough so much they can’t breathe, and then they inspire deeply causing a WHOOP! Patients may have a HIGH WBC of > 20,000. Diagnose with a nasopharyngeal swab. Treat with ERYTHROMYCIN. Use AZITHROMYCIN for children < 1 month of age. The CDC and AAP say “any” macrolide is okay between 1 month and 6 months of age. Recommendations for > 6 months of age are similar. All contacts (even if immunized) need to be given erythromycin for prophylaxis since immunity of the vaccination wanes. Hence the need for Tdap in teens now (more coming up later).
PEARLS: Consider this diagnosis in anyone with a chronic cough. Antibiotic treatment shortens the early stage in which the patient is infectious and has URI-type symptoms (catarrhal stage). If dose NOT decrease the “whooping,” or paroxysmal stage. Erythromycin, clarithromycin and azithromycin are all acceptable agents. Use Azithromycin for children < 6 months of age due to concerns for erythromycin-induced pyloric stenosis. Any macrolide should be okay for after 1 month of age, and because of FDA regulations and much uncertainty as to exactly which macrolide “should” be used in infants, you will NOT be expected to choose one macrolide over another for infants > 1 month of age.
MNEMONIC: If it ends in –ELLA, it’s probably a Gram-negative organism! Brucella, Shigella and Salmonella fit better elsewhere in this chapter.
“MedStudy pediatrics says also not to give IPV if pregnant”
> It’s a precaution only, so you won’t be tested on that nuance – http://www.cdc.gov/vaccines/recs/vac-admin/contraindications-vacc.htm
Btw… why are your reading that?!? And what super-complicated clinical scenario would even require IPV in an unvaccinated teenage pregnant patient? Meaning, is that even a board relevant piece of information that belongs in a board review book for pediatricians?!?
Umm… no. Stick close to your PBR and close all of your other books!
AWESOME! YOU’RE DONE! – WHAT NOW?
Well… you need to get back to your core PBR study material!
At the end of the day, THAT is what is going to help you pass the boards.
AND IF YOU ARE NOT A PBR MEMBER, YOU SHOULD BE!
PBR has had streaks as long as 3 years in a row of 100% pass rates . PBR also has an estimated pass rate of well over 90% for first-time test takers of the ABP initial certification exam (likely over 95% given the insanely low number of requests we get for the 100% Money Back First-Time Pass Guarantee that we offer).
Plus, the “PBR EXPERIENCE” has helped pediatricians pass the boards after they had FAILED UP TO SIX TIMES using other resources. That means they failed SIX times and then passed on their LAST possible chance because they used the PBR! The ABP has a 7-year limit, so if they had failed, they would have had to go BACK to do more residency training!
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Pediatrics Board Review…
YOUR RESOURCE FOR EFFICIENCY IN STUDYING…
ESPECIALLY DURING CRUNCH TIME!
When the initial certification exam coming up, there’s a sense of PANIC that most people go through. BREATHE! If you’ve been studying the PBR thoroughly and you have a fair handle on your test-taking skills, you should be in GREAT shape!
What can you do to MAXIMIZE your remaining study time? Go over your PBR over and over again, focusing on the areas that you still need to master, and skipping the areas that you know very well.
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You can also WATCH almost 30 videos that cover ALL of the PBR through PBR’s Online Video Course, Conference & Live Webinars. You can choose to get access to ALL of the videos, OR you can choose to get access to JUST THE CHAPTERS that you’re struggling with most! Some chapters are as little as $5.
www.PediatricsBoardReview.com/videos
You’ll also get access to some GREAT webinars covering content from each of the chapters.
Some of my favorites include the Acid Base chapter webinar of 2014 and the Fluids & Electrolytes webinar of 2015. I decided to do an impromptu 30-minute session of going over six awesome acid base questions to demonstrate how to easily tear apart acid base questions. People were confused about the delta delta, when to check for compensation, Winter’s formula, etc… but by the end, I was getting comments like, “the light bulb just went off!” The webinar content is only available through the OVC area of the PBR. You get access to the webinars even when you just pay to view a single video 🙂
www.PediatricsBoardReview.com/videos
And if you want to CRANK THROUGH the videos and webinars in just 12-14 hours, you can do so at different speeds by clicking on the gear icon at the bottom of the video and increase the speed up to 2X!
Okay! That’s it!
Now go study in whatever way is going to give you the MOST REPETITION AND LEARNING. If that’s simply reading over and over again, GREAT!
If it’s going to be through video, just remember that the content can be sped up, or slowed down, and is inclusive of tons of great webinars, GREAT!
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And if you’re a non-PBR members who has failed the boards before, or you feel like you need MORE than just great board review material, reach out to us for help with Test-Taking Strategies, test-day planning, anxiety management and much more personalized coaching help as well.
If you don't have a strategic approach to answering standardized exam questions and board-style questions, it's time for you to at least become FAMILIAR with what it means to focus on Test-Taking Strategies.
We've helped physicians finally pass their boards after they had failed MULTIPLE times. Have a look below.
TEST-TAKING STRATEGIES &COACHING
You can also click this link to read a great PBR article that specifically talks about the art of answering board style questions: www.PediatricsBoardReview.com/test-strategies
Alright guys… Team PBR has worked VERY HARD to make available for you all of the tools that that we can think of to help you rock your exam! The rest is up to you.
But trust me, if I can do it… so can you!
And if you're in need of some extra guidance as to how you should approach your exam day and you want to learn more about the actual exam structure, then make SURE you read this article before you take your exam!!!!
