How to Create Effective Board Review Questions

Board review questions should have five elements (these are color coded to match the content of the sample question further below):

Here’s an example of a question containing all 5 elements (again, color coded to match the table above to help identify these elements):

A 3-year-old boy is brought to the emergency department by his grandmother because he’s been acting strange and confused. The grandmother states that three hours prior, she found him sitting on the bathroom floor playing with pills from her pill box. She immediately took the pills away from him and counted them. She noticed that only one pill was missing. Several hours later, she noticed that the boy was behaving erratically and acting confused.

The grandmother has coronary artery disease, hypertension and diabetes and takes aspirin, lisinopril, glyburide, metformin and metoprolol.

On physical examination, the child is mildly agitated, diaphoretic and confused. He is afebrile but somewhat tachycardic. His blood pressure and respiratory rate are normal, and his lungs are clear to auscultation. A 12-lead EKG is normal, except for mild sinus tachycardia. The capillary blood glucose level (“finger stick”) is 40 mg/dL.

Which of the following drugs is the most likely cause of the boy’s condition?

A. Aspirin

B. Glyburide

C. Lisinopril

D. Metformin

E. Metoprolol

Explanations

Answer Choice B (“Glyburide”) is correct. This patient has profound, sustained, symptomatic hypoglycemia. Of the choices given, only glyburide is the most likely drug to cause this with the ingestion of only one pill.

Aspirin (Choice A) does not cause profound hypoglycemia with the ingestion of a single pill. Further, this patient has a normal respiratory rate. Patients with an aspirin overdose are usually tachypneic.

Lisinopril (Choice C) is incorrect. Lisinopril does not cause hypoglycemia. Further, the patient’s blood pressure was reported as normal, making a lisinopril overdose unlikely.

Metformin (Choice D) would have been a reasonable choice if glyburide, a much more potent oral antihyperglycemic agent, was not an option. Here, however, it is an incorrect choice because it is much less likely than glyburide to cause profound, sustained and symptomatic hypoglycemia with the ingestion of one pill.

Metoprolol (Choice E) does not cause hypoglycemia. Further, the physical examination and EKG revealed tachycardia, which is the opposite of what would be expected in a patient with a metoprolol overdose.

Educational Objective: Glyburide can cause a profound, sustained, symptomatic hypoglycemia in a child who ingests even a single pill. Suspect poisoning with an insulin secretogogue in any patient with unexplained profound hypoglycemia.

Analysis and summary

In future articles, we will delve into the purpose of each of these question elements and will discuss how to compose them and how to integrate them with one another. For now, I will just highlight several features which make this question effective:

1. The stem: the scenario is plausible, interesting, and rather straightforward. The physical examination and workup are fairly reasonable, and there is minimal clutter or extraneous material.
2. The “ask” is similarly a straightforward and unambiguous question about the information contained in the stem.
3. The answer choices are extremely concise. They are listed in alphabetical order, which makes it impossible to try to guess the correct answer on the basis of the sequence of answer choices.
4. The explanation section opens with the explanation of the correct response. This allows sharp-minded readers to skip everything else in the section if they “get it.” Explanations can be nuanced in places (e.g., the metformin explanation), but clear. All answer choice explanations are labeled with the corresponding answer choice letter.
5. The educational objective is equally clear and to-the-point.