ABIM Board Review

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ABIM Board Review

• Michael Adams, M.D., FACP
• Associate Professor of Medicine
• Program Director
• Georgetown University Hospital

2
Outline

• ABIM info
• Exam tips
• High yield screening / preventive medicine
• Images, images, images

3
Introduction - ABIM

• tests knowledge AND application of knowledge
• review of previously learned information
• what works to prepare is what works best for
  you

4
Preparation

• General
• study began at least three years ago
• group study
• six or fewer people
• set meeting times
• mock questions

5
Preparation - methods

• Board review resources
• MKSAP (closest to ABIM?) (5/5)
• MedStudy review questions (4.5/5)
• MedStudy videos (4.5/5)
• Mayo Clinic book (4/5)
• Mayo clinic videos (4/5)
• In Training Exam (3.5/5)
• Oxford (2.5/5)
• Audio/Visual
• Practice tests
• Review courses

6
Preparation - methods

• In-training exam
• JGIM 1994 Dec, JGIM 1998 Jun PGY-2 scores highly
  correlate with ABIM results
• JGIM 1992 Jan-Feb 35 ITE had 89 positive
  predictive value, 83 negative predictive value
• use to help guide remaining study

7
Preparation ITE unknowns
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Preparation ITE unknowns
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Preparation - methods

• How many? Is one better?
• JGIM Study
• 2780 ABIM candidates
• mean number of methods 5.2
• no independent correlation with particular type
  of study method
• most predictive program director ratings
• a few is better than one, but too many may signal
  trouble

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ABIM Tips (from ResidencyandFellowship.com)

• Keep your study group small
• Create and devote time to prepare
• Prepare a schedule to study
• Solve questions similar to ABIM exam content
• Pictures Images
• ABIM answering strategies
• Zebras Use exam techniques to your advantage.
  Look for target words in ABIM Internal medicine
  board exam questions. For example
• if you see the word anosmia, think Kallmanns
  syndrome
• scar on left abdomen, think splenectomy and
  look for encapsulated organisms causing sepsis
• if the patient is from the Ohio or Mississippi
  river valleys, think histoplasmosis (CXR/splenic
  calcifications)
• ABIM exam day dont study just before, or during
  the exam dont discuss questions with others

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Preparation - organization

• Subject by subject
• mixed exams (dont get overconfident with
  section exams immediately after studying) - timed
  practice tests
• set pace/deadlines - finish early
• dont inhibit LTM by cramming weak areas last

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The ABIM Exam
13
The ABIM Exam

• Structure
• 1 day, 4 modules, 60 questions, 2 hours each
• ALL single best answer
• images X-ray/smears/pressure tracings/EKGs/gram
  stains/urine sediment
• primary content area 75 (traditional
  medicine subspecialties)
• cross content area 25 (allergy/immunology,
  dermatology, gynecology, neurology,
  ophthalmology, and psychiatry)
• single score required to pass (about 65)
• 2008 91 pass rate for first-time test takers
  (similar for recertification exam)

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The ABIM Exam

• Written by practicing internists
• 85 of questions take place in ambulatory setting
• Emphasizes general knowledge (22 of questions
  taken from prior test)

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2009 ABIM Certification Exam Blueprint
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2009 ABIM Certification Exam Blueprint
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2009 ABIM Certification Exam Blueprint
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Pass rates
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Pass rates
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2009 ABIM Certification Exam Timeline
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The ABIM Exam

• Format
• clinical stem (patient) followed by lead-in
  (last sentence), question, choices
• 75 formulation, not just memorization
• well written, pass by a panel
• no trick questions
• no cutting edge medicine
• uncommon presentation of common diseases

22
Exam Day

• be rested, confident, ON TIME
• bad testers can do well if prepared
• dont study between sessions or exam days
  (inhibition of long term memory, anxiety)
• honor code - dont make a career ending mistake

23
Approach to the Exam

• Answer all questions
• dont get stuck on one question - go back
• about 2 minutes per question
• try to answer before looking at the choices
• dont change answers unless you remember new
  information

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High-yield (I hope) screening / immunizations
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MKSAP 14 question

• A 22-year-old woman is evaluated during a routine
  physical examination. She has mild
  exercise-induced asthma. She does not smoke,
  drinks alcohol only socially, and does not use
  illicit drugs. She has had a total of four sexual
  partners, and currently is in a monogamous
  relationship with a serious boyfriend. She has no
  history of sexually transmitted infections and
  takes an oral contraceptive to prevent pregnancy.
  A recent HIV test was negative. She is due for a
  Pap smear. She has had baseline pulmonary
  function tests.
• In addition to the Pap smear, which of the
  following is most appropriate for this patient?
• A) Encourage use of sunscreen
• B) Prescribe a multivitamin with folic acid
  daily
• C) Screen for Chlamydia trachomatis
• D) Measure fasting plasma glucose

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MKSAP 14 question

• A 22-year-old woman is evaluated during a routine
  physical examination. She has mild
  exercise-induced asthma. She does not smoke,
  drinks alcohol only socially, and does not use
  illicit drugs. She has had a total of four sexual
  partners, and currently is in a monogamous
  relationship with a serious boyfriend. She has no
  history of sexually transmitted infections and
  takes an oral contraceptive to prevent pregnancy.
  A recent HIV test was negative. She is due for a
  Pap smear. She has had baseline pulmonary
  function tests.
• In addition to the Pap smear, which of the
  following is most appropriate for this patient?
• A) Encourage use of sunscreen
• B) Prescribe a multivitamin with folic acid
  daily
• C) Screen for Chlamydia trachomatis
• D) Measure fasting plasma glucose

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Evidence Based Recommendations

• A) Encourage use of sunscreen
• The U.S. Preventive Services Task Force
  concludes that the evidence is insufficient (I)
  to recommend for or against routine counseling by
  primary care clinicians to prevent skin cancer.
• B) Prescribe a multivitamin with folic acid daily
• The USPSTF concludes that the evidence is
  insufficient (I) to recommend for or against the
  use of supplements of vitamins A, C, or E
  multivitamins with folic acid or antioxidant
  combinations for the prevention of cancer or
  cardiovascular disease.
• D) Measure fasting plasma glucose
• The USPSTF concludes that the evidence is
  insufficient (I) to recommend for or against
  routinely screening asymptomatic adults for type
  2 diabetes, impaired glucose tolerance, or
  impaired fasting glucose.

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Evidence Based Recommendations

• C) Screen for Chlamydia trachomatis
• The (USPSTF) recommends screening for chlamydial
  infection for all sexually active non-pregnant
  young women aged 24 and younger and for older
  non-pregnant women who are at increased risk .
  This is a grade A Recommendation.
• The USPSTF recommends screening for chlamydial
  infection for all pregnant women aged 24 and
  younger and for older pregnant women who are at
  increased risk . This is a grade B
  Recommendation.
• The USPSTF recommends against routinely providing
  screening for chlamydial infection for women aged
  25 and older, whether or not they are pregnant,
  if they are not at increased risk .

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MKSAP 14 question on Prostate Cancer screening

• A 45-year-old black man is evaluated for concerns
  about prostate cancer. A good friend was recently
  diagnosed with extensive disease and has a poor
  prognosis. The patient asks if he should have a
  screening test for this disease. He reports
  once-nightly nocturia but has no hesitancy,
  urinary frequency, or dribbling.
• Which of the following is the most appropriate
  course of action for this patient?
• Prostate-specific antigen (PSA) measurement
• PSA measurement and digital rectal examination
• Transrectal ultrasonography
• Transrectal ultrasonography with random biopsies
• Discussion of benefits and harms of PSA testing

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MKSAP 14 question on Prostate Cancer screening

• A 45-year-old black man is evaluated for concerns
  about prostate cancer. A good friend was recently
  diagnosed with extensive disease and has a poor
  prognosis. The patient asks if he should have a
  screening test for this disease. He reports
  once-nightly nocturia but has no hesitancy,
  urinary frequency, or dribbling.
• Which of the following is the most appropriate
  course of action for this patient?
• Prostate-specific antigen (PSA) measurement
• PSA measurement and digital rectal examination
• Transrectal ultrasonography
• Transrectal ultrasonography with random biopsies
• Discussion of benefits and harms of PSA testing

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MKSAP 14 question 3

• A 72-year-old man is evaluated during a routine
  examination. He has a 45-pack-year history of
  smoking but quit smoking 10 years ago. He is fit
  and exercises aggressively. He has no known
  coronary artery disease and no medical problems.
• On physical examination, BMI is 26.4. Pulse rate
  is 62/min, and blood pressure is 118/64 mm Hg.
• Laboratory Studies
• Serum total cholesterol 175 mg/dL
• Serum high-density lipoprotein cholesterol 52
  mg/dL
• Serum low-density lipoprotein cholesterol 102
  mg/dL
• Serum triglycerides 105 mg/dL
• Which of the following is most appropriate next
  step in the management of this patient?
• Electron-beam CT for calcium score
• Carotid artery ultrasonography
• Ultrasound to evaluate for abdominal aortic
  aneurysm
• Statin therapy

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MKSAP 14 question 3

• A 72-year-old man is evaluated during a routine
  examination. He has a 45-pack-year history of
  smoking but quit smoking 10 years ago. He is fit
  and exercises aggressively. He has no known
  coronary artery disease and no medical problems.
• On physical examination, BMI is 26.4. Pulse rate
  is 62/min, and blood pressure is 118/64 mm Hg.
• Laboratory Studies
• Serum total cholesterol 175 mg/dL
• Serum high-density lipoprotein cholesterol 52
  mg/dL
• Serum low-density lipoprotein cholesterol 102
  mg/dL
• Serum triglycerides 105 mg/dL
• Which of the following is most appropriate next
  step in the management of this patient?
• Electron-beam CT for calcium score
• Carotid artery ultrasonography
• Ultrasound to evaluate for abdominal aortic
  aneurysm
• Statin therapy

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Evidence Based Recommendations

• Electron-beam CT for calcium score
• The USPSTF recommends against (D) routine
  screening with resting ECG, exercise treadmill
  test (ETT), or electron-beam computerized
  tomography (EBCT) scanning for coronary calcium
  for either the presence of severe coronary artery
  stenosis (CAS) or the prediction of coronary
  heart disease (CHD) events in adults at low risk
  for CHD events.
• The USPSTF found insufficient evidence (I) to
  recommend for or against routine screening with
  ECG, ETT, or EBCT scanning for coronary calcium
  for either the presence of severe CAS or the
  prediction of CHD events in adults at increased
  risk for CHD events.
• Carotid artery ultrasonography (D)
• Statin therapy

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Evidence Based Recommendations

• The USPSTF recommends one-time screening for
  abdominal aortic aneurysm (AAA) by
  ultrasonography in men aged 65 to 75 who have
  ever smoked. (B recommendation)
• ever smoker 100 cigarettes / lifetime

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• Bladder Cancer
• Breast Cancer
• Cervical Cancer
• Colorectal Cancer
• Gynecologic Cancers
• Lung Cancer
• Oral Cancer
• Ovarian Cancer
• Pancreatic Cancer
• Prostate Cancer
• Skin Cancer
• Testicular Cancer
• Thyroid Cancer
• Tobacco Use
• Vitamin Supplementation to Prevent Cancer and CHD

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Breast Cancer

• The (USPSTF) recommends screening mammography,
  with or without clinical breast examination
  (CBE), every 1-2 years for women aged 40 and
  older.
• The USPSTF concludes that the evidence is
  insufficient to recommend for or against teaching
  or performing routine breast self-examination
  (BSE).

B recommendation
I recommendation
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Chemoprophylaxis for Breast Cancer

• The U.S. Preventive Services Task Force (USPSTF)
  recommends against the routine use of tamoxifen
  or raloxifene for the primary prevention of
  breast cancer in women at low or average risk for
  breast cancer.
• The USPSTF recommends that clinicians discuss
  chemoprevention with women at high risk for
  breast cancer and at low risk for adverse effects
  of chemoprevention. Clinicians should inform
  patients of the potential benefits and harms of
  chemoprevention.

D recommendation
B recommendation
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Cervical Cancer

• The USPSTF strongly recommends screening for
  cervical cancer in women who have been sexually
  active and have a cervix.
• The USPSTF recommends against routinely screening
  women older than age 65 for cervical cancer if
  they have had adequate recent screening with
  normal Pap smears and are not otherwise at high
  risk for cervical cancer .

A recommendation
D recommendation
40
Cervical Cancer

• The USPSTF recommends against routine Pap smear
  screening in women who have had a total
  hysterectomy for benign disease.

D recommendation
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Cervical Cancer

• The USPSTF concludes that the evidence is
  insufficient to recommend for or against the
  routine use of new technologies to screen for
  cervical cancer.

I recommendation

• The USPSTF concludes that the evidence is
  insufficient to recommend for or against the
  routine use of human papillomavirus (HPV) testing
  as a primary screening test for cervical cancer.

I recommendation
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(No Transcript)
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Colorectal Cancer

• The USPSTF recommends screening for colorectal
  cancer (CRC) using fecal occult blood testing,
  sigmoidoscopy, or colonoscopy, in adults,
  beginning at age 50 years and continuing until
  age 75 years.

A recommendation
NB recall the difference between hyperplastic
and adenomatous polyps and how they affect colon
cancer surveillance / screening
44
Colorectal Cancer

• Unlikely to appear on 2009 exam
• Starting earlier in AA patients (45)
• CT colonography (virtual)
• Shorter screening interval with sessile (flat)
  polyps
• Patients age 75-85 (There may be considerations
  that support colorectal cancer screening in an
  individual patient. grade C)
• Fecal DNA testing

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Prostate Cancer

• The U.S. Preventive Services Task Force (USPSTF)
  concludes that the evidence is insufficient to
  recommend for or against routine screening for
  prostate cancer using prostate specific antigen
  (PSA) testing or digital rectal examination (DRE).

I recommendation
46
PLCO trial
47
NEJM European trial
Absolute risk reduction 0.71 death / 1000
men Number needed to screen to prevent one death
1410
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Prostate Cancer

• Unlikely to appear
• Finasteride for prophylaxis
• If it appears, its wrong
• Saw Palmetto

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MedStudy Question

• A healthy 33-year-old woman comes to establish
  care in your practice. She reports no breast
  symptoms, her age at menarche was 14, and she has
  no children. She notes a family history of
  early-onset breast cancer in her 39-year-old
  sister (diagnosed at age 35), her mother
  (diagnosed at 37 years), and a maternal aunt
  (diagnosed at 42 years). Her maternal grandfather
  died of prostate cancer.
• For this patient, which of the following is
  recommended regarding screening for breast cancer
  and/or strategies to reduce her risk?
• A) Begin tamoxifen or raloxifene
• B) Bilateral breast ultrasound
• C) BRCA testing
• D) Genetic counseling
• E) C and D

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MedStudy Question

• A healthy 33-year-old woman comes to establish
  care in your practice. She reports no breast
  symptoms, her age at menarche was 14, and she has
  no children. She notes a family history of
  early-onset breast cancer in her 39-year-old
  sister (diagnosed at age 35), her mother
  (diagnosed at 37 years), and a maternal aunt
  (diagnosed at 42 years). Her maternal grandfather
  died of prostate cancer.
• For this patient, which of the following is
  recommended regarding screening for breast cancer
  and/or strategies to reduce her risk?
• A) Begin tamoxifen or raloxifene
• B) Bilateral breast ultrasound
• C) BRCA testing
• D) Genetic counseling
• E) C and D

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BRCA screening

• Who is at risk?
• non-Ashkenazi Jewish women
• 2 first-degree relatives with breast cancer, 1 of
  whom received the diagnosis at age 50 years or
  younger
• 3 or more first- or second-degree relatives with
  breast cancer regardless of age at diagnosis
• both breast and ovarian cancer among first- and
  second-degree relatives
• a first-degree relative with bilateral breast
  cancer
• 2 or more first- or second-degree relatives with
  ovarian cancer regardless of age at diagnosis
• a first- or second-degree relative with both
  breast and ovarian cancer at any age
• history of breast cancer in a male relative.

52
BRCA screening

• Who is at risk?
• Ashkenazi Jewish women
• any first-degree relative (or 2 second-degree
  relatives on the same side of the family) with
  breast or ovarian cancer.

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BRCA screening

• Average/low risk women?
• important adverse ethical, legal, social
  consequences of testing
• important harms of interventions such as
  prophylactic surgery, chemoprevention, or
  intensive screening in non-high risk women
• potential harms of routine referral for genetic
  counseling or BRCA testing in these women
  outweigh the benefits

54
BRCA screening

• High risk women?
• prophylactic surgery for high risk women
  significantly decreases breast and ovarian cancer
  incidence. Thus, the potential benefits of
  referral and discussion of testing and
  prophylactic treatment for these women may be
  substantial.
• these women would benefit from genetic
  counseling that allows informed decision making
  about testing and further prophylactic treatment.

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BRCA screening

• The USPSTF recommends against routine referral
  for genetic counseling or routine breast cancer
  susceptibility gene (BRCA) testing for women
  whose family history is not associated with an
  increased risk for deleterious mutations in
  breast cancer susceptibility gene 1 (BRCA1) or
  breast cancer susceptibility gene 2 (BRCA2).

D recommendation
56
BRCA screening

• The USPSTF recommends that women whose family
  history is associated with an increased risk for
  deleterious mutations in BRCA1 or BRCA2 genes be
  referred for genetic counseling and evaluation
  for BRCA testing.

B recommendation
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Vaccinations

• Td
• pneumovax
• influenza
• Hepatitis B
• Varicella
• Hepatitis A
• Polio
• MMR
• Meningococcus

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Question

• Your healthy 52 year old patient requests the
  influenza immunization. It is the first week of
  December, and the CDC lists influenza activity in
  your area as no activity. Your office just ran
  out of inactivated influenza vaccine. The
  patient has no medical problems, takes no
  medications, and has no allergies.
• What is the best strategy for this patient?
• Live, attenuated intranasal flu vaccine (FluMist)
• Prophylaxis with oral oseltamivir (Tamiflu)
• Prophylaxis with zanamivir (Relenza)
• Wait until more inactivated influenza vaccine
  arrives

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Question

• Your healthy 52 year old patient requests the
  influenza immunization. It is the first week of
  December, and the CDC lists influenza activity in
  your area as no activity. Your office just ran
  out of inactivated influenza vaccine. The
  patient has no medical problems, takes no
  medications, and has no allergies.
• What is the best strategy for this patient?
• Live, attenuated intranasal flu vaccine (FluMist)
• Prophylaxis with oral oseltamivir (Tamiflu)
• Prophylaxis with zanamivir (Relenza)
• Wait until more inactivated influenza vaccine
  arrives

60
Vaccinations

• TD
• Every 10 years, rebooster at 5 years for
  tetanus-prone exposure (incl. bites)
• Pneumovax
• 23 strains
• Mortality in asplenic patients from pneumococcal
  sepsis
• Influenza (inactivated)
• Over age 50
• Hemoglobinopathies, ASA use
• Guillian-Barre / egg allergy
• Live, attenuated influenza vaccine flu mist
• Not for patients 50 or immunosuppressed

61
Question (Unknown)

• You examine a 37 year old man for an annual
  physical exam. He has no chronic medical
  problems, takes no medications, and does not
  smoke or drink alcohol. He is homosexual and
  active with one partner for the past 6 months.
• He works as an accountant and has no travel
  outside the U.S.
• His exam is normal.
• In addition to testing for HIV, sexual risk
  counseling, and routine blood work for
  cholesterol, what other preventive health measure
  is appropriate?
• A) Placing a PPD
• B) Hepatitis A and B vaccines
• C) Pneumococcal vaccine
• D) Hepatitis B vaccine
• E) None of the above

62
Question (Unknown)

• You examine a 37 year old man for an annual
  physical exam. He has no chronic medical
  problems, takes no medications, and does not
  smoke or drink alcohol. He is homosexual and
  active with one partner for the past 6 months.
• He works as an accountant and has no travel
  outside the U.S.
• His exam is normal.
• In addition to testing for HIV, sexual risk
  counseling, and routine blood work for
  cholesterol, what other preventive health measure
  is appropriate?
• A) Placing a PPD
• B) Hepatitis A and B vaccines
• C) Pneumococcal vaccine
• D) Hepatitis B vaccine
• E) None of the above

63
Vaccinations

• Hepatitis B
• Indications
• sexual exposure - multiple, homosexual
• health care workers
• IVDA
• HIV (50-70 seroconversion)
• infants born to HBsAg positive women
• post-exposure prophylaxis
• depends on type of exposure, patient risk
• high HBIG Hep B series
• low Hep B series or booster

64
Vaccinations

• Varicella
• Live, attenuated vaccine
• Pregnant women pneumonia
• Hepatitis A
• Indications endemic areas, homosexual men, IVDA,
  liver disease, occupational risk
• Takes three weeks to be reliably protective
• Polio
• IPV only

65
Vaccinations

• MMR
• Live, attenuated (avoid in immunosuppression,
  pregnancy)
• Booster adults born after 1956
• Neomycin allergy (mumps, rubella)
• Post-exposure prophylaxis
• High risk booster one arm, IG other arm
• Low risk booster alone, in most cases

66
Vaccinations

• Meningococcus (post-exposure prophylaxis)
• High risk only
• household contacts
• 4 hours spent with patient for 5 of 7 days prior
• dorms, barrack roommates, day care
• mouth-to-mouth
• prophylaxis
• rifampin (600mg q 12h x 4) resistance
• cipro 750 mg x 1
• ceftriaxone 250 mg IM x 1

67
Vaccinations

• Could appear on 2009 exam
• -Gardasil (age 9-26)
• -Zostavax (over 60, immunocompetent)
• -TDap in adults (substitute once for Td) up to
  age 64

68
Non-Cancer screening prophylaxis

• For which of the following patients is it
  recommended to screen for diabetes?
• A) A 55-year old man with a body mass index (BMI)
  of 34
• B) A 48 year old woman whose mother has type II
  diabetes
• C) A 44 year old man whose last three blood
  pressure readings are 138/85
• D) A 62 year old woman with hyperlipidemia
• E) A 38 year old man who asks for a blood sugar
  test because he has a sweet tooth

69
Non-Cancer screening prophylaxis

• For which of the following patients is it
  recommended to screen for diabetes?
• A) A 55-year old man with a body mass index (BMI)
  of 34
• B) A 48 year old woman whose mother has type II
  diabetes
• C) A 44 year old man whose last three blood
  pressure readings are 138/85
• D) A 62 year old woman with hyperlipidemia
• E) A 38 year old man who asks for a blood sugar
  test because he has a sweet tooth

70
Diabetes

• The USPSTF recommends screening for type 2
  diabetes in asymptomatic adults with sustained
  blood pressure (either treated or untreated)
  greater than 135/80 mm Hg.  (2008)

B recommendation
71
Non-Cancer screening prophylaxis

• Unlikely to appear on 2009 exam
• -ASA for stroke prevention in women 55
• -Widespread HIV screening, unless they give you
  an increased prevalence of HIV in the population
  (e.g., rapid testing in a city ER)

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75
Howell-Jolly body (asplenism)
76
Reed-Sternberg Cell (Hodgkins)
77
Pseudo Pelger-Huet cell (myelodysplasia)
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(No Transcript)
79
Aortic Regurgitation
80
Aortic Stenosis
81
COPD
82
Variable intrathoracic obstruction
83
Variable extrathoracic obstruction
84
fixed obstruction
85
Megaloblast (hypersegmented poly)
86
Oxalate crystal
87
CPPD crystal (pseudogout)
88
MSU crystal (gout)
89
Shows the axis of the first-order polarizing
filter
90
(No Transcript)
91
Auer rods
92
PTX
93
RBC cast
94
Smudge cell
95
Erysipelas
96
MAHA (microangiopathic hemolytic anemia)
97
P. Falciparum (banana-shaped gametocyte)
98
P. Falciparum (small parasite, multiply infected
RBCs)
99
Acanthosis nigricans
100
(No Transcript)
101
impetigo
102
Cavitary lesion- TB
103
meningococcemia
104
Nikolskys sign
105
CMV retinitis
106
HIV-related lipodystrophy
107
A 22 year old woman is seen for this rash. She
was on a camping trip in the Shenandoah Valley
one month ago. What test is needed to confirm
the diagnosis?
108
Molluscum contagiosum
109
smallpox
110
Disseminated cryptococcemia
111
CLL
112
Dermatomyositis Gottrons papules
113
WPW type B
114
WPW and a fib
115
Herpetic whitlow
116
Herpes ophthalmicus
117
Perifollicular hemorrhages - Scurvy
118
(No Transcript)
119
Dermatitis herpetiformis
120
Torsades de Pointes
121
Cystinuria (flat, hexagonal)
122
Saddle-nose syphilis, relapsing polychindritis,
Wegeners, sarcoidosis, leprosy
123
Pityriasis rosea (Herald patch)
124
bronchiectasis
125
Cushings
126
Heliotrpoe rash - dermatomyositis
127
Wilsons disease
128
LEMS
129
Good luck!!