ABP Board Pearls: 6 High-Yield Topics for Your Pediatrics Exam

Welcome to high yield topics for the ABP exam! Today we’ll discuss six topics commonly tested on boards: well-appearing patients that may not actually be well; fractures that may have negative imaging findings; headache red flags; the diagnostic evaluation of fever in small children; foreign body aspiration; and systemic rash syndromes! We’ll use clinical vignettes and lists of risk factors to help you break down these topics and nail every board question on them!

For help fitting these topics into your study schedule, read our guide on how to approach ABP board prep.

1. “Well-Appearing” May Not Be Well

There are lots of reasons a patient you think is well-appearing may not be. There are dangerous diseases which present with only minimal symptoms. There are patients like infants and those developmentally disabled who can’t exhibit severe symptoms. 

Case Examples:

• Infants with fever
  Infants, especially less than 3 months old, may have few symptoms or signs of illness. For example, a well appearing 1 month old with fever still requires blood and urine testing to rule out sepsis.
• Appendicitis with minimal early findings
  Even if patient has no fever or minimal pain, if any peritoneal signs are present → evaluate for appendicitis.
• MIS-C initially thought viral
  Many dangerous diseases present initially as non-specific viral syndromes, including MIS-C. Pay attention to fevers greater than 4 days and worsening systemic symptoms to trigger a work up. MIS-C has prominent GI symptoms, meningismus and rash.
• Orbital abscess without fever initially
  Even significant infections like orbital cellulitis may have only edema and mild pain, without fever initially.
• DKA discovered during weight-loss workup
  Patients with mild DKA may appear overall well with only mild symptoms of nausea, abdominal pain and weight loss. Maintain a high index of suspicion whenever weight loss is present.
  
  

Board Pearls – Red Flag Combinations:

Remember the following patient presentations:

• Pain severe enough to wake from sleep – malignancy, fracture
• Abdominal pain with jumping – appendicitis, peritonitis
  
• Persistent fever >5 days – malignancy, sepsis, rheumatologic disease
• Weight loss + subtle symptoms – DKA, adrenal insufficiency, malignancy 

2. Refusal to Bear Weight = Fracture Until Proven Otherwise

The classic patient is a happy toddler who fell down an hour ago, has a normal X-ray, but still refuses to walk. Maybe it’s just a sprain? Maybe not! Remember this list:

Fractures with Possible Normal X-Rays:

• Toddler’s fracture/Spiral fracture of distal tibia
  Watch for a twisting injury to the leg. On exam the leg may look normal with only mild tenderness!
• Any Salter-Harris type 1 (Example: Distal fibula after ankle injury)
  These may present like a simple ankle sprain, but aren’t! Focus on tenderness along the epiphyseal plate.
• Stress fractures
  These are true fractures that need splinting. Most commonly in the medial distal tibia, the same location as medial tibial stress syndrome, but symptoms will be more severe.
• Slipped capital femoral epiphysis (early on)
  Typically seen in obese children, SCFE may initially only have hip discomfort with a normal X-ray. Consider MRI.
• Scaphoid fracture
  Usually after a fall on an outstretched hand (FOOSH), any patient with snuffbox tenderness of the wrist requires a thumb spica splint.

Board Pearls – Empiric Splinting Indicated if X-ray is Normal but…

Each of the following on this list indicates a possible underlying fracture, so splint empirically and follow up!

• Refusal to walk
• Fussy with manipulation
• Localized severe tenderness

3. Severe Headache Red Flags

The boards loves asking about headaches, and for good reason – they are common, often benign, but potentially deadly! Focal neurologic deficits on exam are always a red flag – even if the patient is otherwise well, get brain imaging!

High Risk Headache Features → Consider Imaging

This list describes headache features that may suggest increased intracranial pressure. Lying supine overnight increases ICP naturally, so any further elevation from a mass will cause night or morning symptoms.

• Headache waking from sleep
• Morning headache
• Worsened by Valsalva (coughing, exerting, etc)
• Changing over time: Frequency, intensity
• Associated with altered mental status, vomiting, ataxia
• Occipital location

High Risk Exam Findings → Obtain Imaging

These are the most commonly seen early onset signs of increased ICP. If the patient presents with these findings, strongly consider imaging.

• Abnormal eye movements
• Gait abnormality or ataxia
• Weakness
• Papilledema 

Board Pearls – Classic Brain Tumor Presentation:

• Remember the classic presentation: progressive course of morning vomiting and headache, with papilledema and focal neuro deficits on exam. Get brain imaging right away!
  

4. Fever Without Source in <2 Years

ABP loves testing you on fevers! Remember, the priority is to get blood cultures and urine testing on patients at risk for invasive bacterial infections. The following lists are crucial:

Fever: Risk Factors for Invasive Bacterial Infection → Consider Urine Testing and/or Blood

This list describes features that make a fever higher risk for being caused by a bacterial source. If the patient has a fever like this, consider blood and/or urine testing to rule out IBIs like UTI and bacteremia.

• Greater than 102.2F (39 C)
• Greater than 48 hours duration
• Fever that recurs after initial resolution

Patient: Risk Factors for Sepsis → Consider Blood Work

This list shows patient factors that increase the likelihood they may have sepsis, particularly in the setting of fever. Infants less than 3 months are one of the highest risk groups – always consider blood work and even lumbar puncture if indicated.

• Age less than 3 months
• Ill-appearing
• Unimmunized
• Immunodeficiency

Patient: Risk Factors for UTI → Consider Urine Testing

This list contains patient factors that increase their risk for having a UTI in the setting of fever. Younger patients, especially females, are at highest risk. Remember, if there’s no identifiable fever source on exam, consider urine testing!

• No signs or symptoms of another fever source
• Female: less than 2 years old
• Uncircumcised male: less than 1 year old
• Circumcised male: less than 6 months old
• History of UTI or urogenital abnormality

Board Pearls:

• Memorize fever and patient risk factors for bacterial infections!
• <2 yrs with fever without source → always consider UA
• Urine dip with leukocyte esterase alone → may NOT be UTI

5. Foreign Body Aspiration

It’s easy to catch the kid who just inhaled a grape and is actively choking. It’s harder to catch the actual most common presentation of foreign body aspiration: a subacute cough syndrome with few other findings. 

Historical Features of Choking or Coughing Episode:

• May be days or weeks before presentation
• Usually self-limited
• Followed by symptom-free or cough-only period
• May be forgotten by caregiver

Clinical Presentation:

Most foreign body aspirations will have at least one of the below findings, whether acute, subacute or chronic.

• Subacute cough
• Stridor
• Unilateral wheeze on exam
• XR normal for small, radiolucent objects (eg., peanut)
• XR with unilateral hyperinflation or atelectasis if obstruction
• Fever if post-obstructive pneumonia

Board Pearl:

Obtain bronchoscopy if any of the above findings suspicious for aspiration are present, even if the child is overall well-appearing and without systemic symptoms!

6. Rash + Systemic Symptoms = Think Bigger

Children get rashes all the time – so which ones are dangerous? Whenever systemic symptoms or signs are involved, think about bacterial and immunologic conditions. For boards, remember these syndromes!

Board Pearls – Rash Syndromes:

• Palpable purpura on legs + joint pain only → think HSP
  We’re used to remembering HSP involves GI and renal findings like abdominal pain or hematuria. But these findings are delayed in onset, and often missing early on!
• Rash with neurologic findings → think meningococcemia, Rocky Mountain spotted fever, viral encephalitis, or MIS-C
• Meningococcemia = petechial or purpuric rash + fever. With these findings, rule out meningococcal disease first and foremost.
• RMSF = Papular rash of wrists, ankles with meningismus. The fever and headache are prominent in RMSF, but the rash is delayed in onset until days 3-5. Thrombocytopenia is classic. Urticaria is not typical and suggests another diagnosis.
  
• HSV encephalitis = Vesicular rash + confusion, AMS. For any vesicular rash in an encephalitic patient, start empiric acyclovir as soon as possible!
• MIS-C = Rash + GI-prominent sepsis syndrome. These patients are systemically ill with meningismus as well. Look for a recent COVID diagnosis.
• 5 days of fever with late-onset rash → think roseola
  If well-appearing patient, no need for sepsis work up even despite prolonged fever. Remember, roseola may cause sterile pyuria (ddx: UTI) and erythematous tympanic membranes (ddx: AOM), so don’t overtreat for something that isn’t there!
• Kawasaki and scarlet fever both have fever, rash, pharyngeal erythema and strawberry tongues
  But Kawasaki has prolonged symptoms >5 days, while scarlet fever remits by days 3-5 and the rash fades around day 6. Kawasaki’s lymphadenopathy is usually painless, while scarlet fever’s is painful. Both may have epidermal desquamation.

Final thoughts

That wraps up our high yield ABP topic discussion! Remember not to be fooled by certain well-appearing patients, especially febrile infants and patients early on in their course of illness – they still need a work up! For fractures, remember the list of those with initially negative imaging. Regarding headaches, memorize the red flag symptoms and signs, and always get imaging for focal neuro signs! With fever in children under 2 years old, remember the risk factor lists we reviewed, because boards loves testing on those.

Remember the classic presentation of foreign body aspiration, and its subacute counterpart. And finally, now you can distinguish different rash syndromes by their associated characteristics. As you review these topics, practice identifying the key clues in each vignette and explaining why the other answer choices are incorrect. For more ways to strengthen your preparation, explore common pitfalls in ABP prep and how to avoid them. Good luck on your exam!

The post ABP Board Pearls: 6 High-Yield Topics for Your Pediatrics Exam appeared first on Elite Medical Prep.