Steven I McLaughlin DVM, MPH, DACVPM
17 minutes


Just to briefly introduce myself, I am Doctor Zuku.  I'm the founder and president of Zuku Review, although now we're many vets in many expert areas and we've been doing this for 15 years now. I'm a graduate of Cornell Class of 91. I did mix practice in upstate New York and also I did mix practice type work in the Peace Corps. I was in Ecuador, in the high Andes. I came back from South America and I got an MPH and I ended up working for nine years as a public health epidemiologist doing international work. And I worked in all over India, China, Africa. Every now and then there'd be an outbreak somewhere, and I get to go on a plane to somewhere like Fiji or Myanmar back when it's still close. It was very exciting wor.  if any of you guys have interest in public health work, just drop me a line. That's my direct email. Also, for those of you who are here, I really appreciate that you came. I am Doctor Zuku. You have now met me and do by all means, copy that email if you ever want to consult with me or any of our experts about how to get traction for your tests.


OK, so I think we're at the noon hour. Just about last few people are trickling in. As I said, if you have questions for me, just drop me a line there in the chat room. I'll keep an eye on that as we go. Everything we talk about today, I hope that you find it useful, and I also hope you find it entertaining, this is kind of a fun talk. People love to hear those horror stories about things that went wrong, but they also like to laugh a little bit. So I hope you can tell by now I'm not very formal and you don't need to be either. So without further ado, off we go.


To achieve great things, two things are needed, a plan and not quite enough time. This is not news to any vet student anywhere, right? I'm not suggesting that you should try to prepare for your boards without a plan, you should have a plan. But if you imagine that you're going to learn every last detail and factoid of the universe of veterinary medicine, by the time you sit down to take your NAVLE®, that's impossible. And you're only going to make yourself crazy trying to learn all those details. It's really not the name of the game. The real name of the game here is to triage information.


This is your basic recipe for any big test. Number one, studies of adult learning have shown across every discipline you want to name: physicians, nurses, architects, lawyers, vets.  People who do practice questions that resemble the real test as a fundamental part of their prep, like two thirds of their study time in a given week, those people consistently outperform folks who only studied the books or only did study groups or whatever it might be. This is the foundation of how you prepare for a high consequence standardized test. OK, hand in hand with that, when you study the books and notes, maybe a third of your time in any given week for boards, make sure you use pictures. Our brains are wired for pictures. If I say to you, you are presented with a seven year old female intact miniature poodle, never been spayed. She's got a big pot belly, she's PU/PD and wait for it, it's got a temperature of one hundred five point nine Fahrenheit. Now tell me in chat, everybody, what do you guys think that big pot belly poodle has got going on with the fever and the PU/PD?  There we go, a big ole PIO, good, yeah, so most people said Pyometra, that's correct. A few people said what I would say is the main differential for this. What do you think of it's the same dog, miniature poodle, potbelly, PU/PD, no fever. Now, what's our differential? Cushing's, exactly right.  So, Cushing's is definitely on your differential list, but usually with Cushing's no fever. OK, so we got a PIO now in your head, did you have a picture of that pot belly poodle? Right. Even when the question doesn't have an image, an image is what pops up into your head, and to that picture we can hang information. I used to see these in practice pretty commonly. Probably once a month. We'd have a cat or dog with this between March and October, you know. So let's say you're presented with this dog and you think it's a PIO on the boards. They might not ask you what it is. They might say, what are you going to do, just like in real life or what are you going to do for a PIO? Everybody, same day. Tory, that's correct, we're going to surgery.  99 times out of 100, you're doing the spay, OK? One time out of 100, they may want to preserve fertility and that's a whole other animal, but it's it's not that common. OK, you're going to surgery. So, boom. An image is where it starts. If you use images when you study those images are the thing, they're like mental Velcro, it helps information stick in your head and throughout this talk that's my second big point is I'm going to try to convince you that using images will help you remember better. You don't know everything about PIO, but you know a few things. You know that the main differential could be Cushing's and you know, you want to take it out. Finally, I'll address this more later, but if you can find a way to leave time free before your test to redo your practice questions with the clock ticking and time test mode like the real thing, and to rereview your notes and books that re-review is critical. It reinforces stuff you've been studying for months and this goes for test you might have next week. Try to leave 24 hours free, OK, and rereview. For boards, it's a big test, try to leave a month free.


OK, let me see if I convince you of a new way to do questions, don't read the question first, read the answers and ask yourself what kind of question might it be looking at and the kinds of questions you always see in real life and on the boards are what's my diagnosis? What's my key differential? What's my test? What's my prognosis? What do I do? How do I treat it? What I tell the owner? What kind of question you guys think we're looking at here. Just tell me in chat. Yeah, what's your diagnosis? That's step one, took like four seconds and now you're in the ballpark. Step two, if a question is images, look at the pictures. So I look up here and I say this appears to be a dog and look down here and say this appears to be an ultrasound and I'm in serious trouble. But OK, third step. Now, you spent maybe eight seconds just getting in the ballpark. Third step is you're allowed to read the question. Six month old terrier-mixed dog is presented with a three day history of vomiting, diarrhea and lethargy. So this is common, common, common. This is the acute abdomen or acute-ish abdomen. We used to see dogs like this a couple times a week, OK? And 99 times out of 100, they got in the garbage and it's veterinarian's discretion. He's going to poop it out or puke it out. One time out of 100, the dog ate a bunch of dental floss where the dog swallowed a rubber duck or it's a schnauzer and he's got pancreatitis. But it's one of the other things. And you will be up nights worrying if it's one of those other things. OK, so it's acute acute-ish abdomen. Fine. I still don't know what I got. I'll go back and look at my pictures. I say, well, obviously, it's. Still a dog, and then I look down here and I say, oh, I see what's going on. This dog swallowed a cinnamon roll, didn't he? What's this target lesion? Everybody just tell me and chat. This is your correct answer. Kathy, Kayleigh, very, very good. This is intussusception. Very good. So this is typically a young dog problem. When I was in practice, I bet we saw one or two a year. What if the question isn't what is it, but what do you do? This is classic on boards. They expect you to know what it is and they ask you, what do you do? What are you going to do for this dog? Yeah, Kathleen, we're going to surgery. Good job. Going to surgery, it's basically an exploratory. A lot of times you find that intussusception, you tease it out, and the part that was intussuscepted is nice and pink and you say, hooray, right. And you put it back in. And sometimes you tease that part out in the one that was on the inside is black and purple, and then we're doing a resection and anastomosis and we're going to cross our fingers hope it doesn't leak but, the value of this is this picture has been in front of your eyes for about one minute. I guarantee you, if you do any small animal work at all, you are likely to see another one of these sometime in the next couple of years. And the next time you see an ultrasound with this cinnamon roll, with this target lesion, just from this one minute or so alone of seeing this picture, you're going to go, oh, man, you know, I have seen this before. That's the cinnamon roll. What was that? Oh, yeah, that's intususception. I know what I'm doing this afternoon. I'm going to surgery. So use these pictures as your toe hold on information.


Here's another example. Cervical ventroflexion in a cat. OK, quick and dirty from Clin Path. What is the electrolyte problem with this cat? This is pathamnemonic for a particular electrolyte imbalance. Yeah, very good Allison, this is hypocalemia. Good job. Low potassium. Now on the boards, they're usually not quite that cut and dried. Instead they're going to give you a case presentation and some findings they're going to ask you to interpret. So this might be they'd say you've got a fourteen year old male neutered cat for about three or four months. He's been losing weight, getting skinny, rough hair coat. Seems like maybe he's drinking more water than normal. Owner doesn't really know if he's peeing more. And today he presents like this. And the question isn't what is it? The question might be like, what's the underlying body system that's having a problem here? OK, so what is the pathophysiology behind this problem? And, you know, if you see any cats at all, you're going to see you may not see this hypocalemia thing, but you certainly will see cats with this pathophys. This is super classic. When we say about cats, if you live long enough, you're going to outlive what part of your anatomy. And I've got one one of my cats has got this, in fact, she's been living with it for three or four years. Yeah, very good, Mary, this is kidneys. This is chronic renal disease. Good job. And basically, if cats live long enough, they tend to outlive their kidneys. Often these are fun to palpate or at least rewarding because you can feel like these small, hardened kidneys in a skinny cat. And so, you know, if the question isn't what is it, but what do you do, it might be, you know, you need to get them on a renal friendly diet, high quality protein, all the water they can drink, monitoring with B1 and creatinine on a regular basis, stuff like that. If it was, what do you test for? You'd say, give me a a U.A. and see if you can concentrate. Give me a panel. OK, so boom out of that one. Picture a lot of information and that is how you learn fast and that's how you get information to stick.


You guys, you get the Zuku review question of the day, which is free. You know that if you get an image, particularly radiographs, just click on the image. You make it big. So if you get an image question, look at the image. Don't even read the question. Just look at the image. I look at this image and I say, oh, it's so obvious this animal has a foreign body right here. Right. Anybody want to tell me what they think that is on this elbow? This is and it's pretty obvious. Very good. Yes, very good, Megan, this is an ununited anconeal process. OK, so right there you see that big gap there. Normally there is a growth plate there in the growth plate didn't fuse. You don't even know what the question is. And you can already tell me something about this, I bet. Is this a big dog or little dog? Yeah, exactly, this is a big dog, is this elbow from a young dog or an old dog? Exactly, this is a young, big dog problem now on the boards, if they ask you, what do you do, what would you do? Well, you're going to try to stabilize the elbow, minimize activity, change what you feed him, but you're in the ballpark. Then you can read the question. So if you get a picture, particularly in Zuku, click on it, make it big, and you can often get in the ballpark. And even if you don't know much about ununited anconeal processes process, you're in the ballpark. You can probably figure it out. And that's how you be, that's how you can be strategic.


Just be aware NAVLE®'s style questions can be a little harder than what is what is this I'm looking at? OK, they're going to ask you something where they expect you to be able to interpret what you're looking at and then kind of make what I would call a leap to say something about it. So here's an example. This will be your next poll question. By the way, an adult male neutered barn cats presented after being kicked by a horse near the left shoulder. Cat is non-weight bearing and left foreleg possess some fractures. Cat is B.A.R., but you see in ipsilateral miosis, ptosis, enophthalmos and protrusion of the third eyelid O.S. I think most of you already know what's going on in the head. But check this out on the boards. The question may not be as simple as what's happening in the head. The question may be this or something like it. Where is the primary lesion? Now, remember, from clinical neuroanatomy, we spend a lot of time trying to find to localize lesions. Right. To find like the one place that will explain all the signs. So where can I put one lesion that will give me Horner's in the head and also have this trauma thing that happened down in the shoulder? This is a pretty classic presentation, by the way, trauma to the shoulder when I was in practice, I see this in like a big dogs. They come in their non weight bearing in the leg, probably some fractures. And they also had Horner's. Good job, keep them coming, guys. Just a few more seconds, if you don't know what it is, it's fine. Just guess we'll talk about this throughout. But basically when you don't know, admit it quickly, then cross out the choices you don't like the look of. And guess that's literally the best way you can play the game. OK, a few more seconds and three. Two. One, get them in and close. So the most people said cervical spinal cord was where they thought the lesion was, but most likely that's not correct, that the lesion is almost always going to be right here in the brachial plexus. That's that big knot of nerves in the armpit. This is a brachial plexus avulsion, which you see with trauma to the shoulder sometimes. And you'll get a secondary like interruption, I believe, of the sympathetic pathway up the neck. And that's how you get your Horner's. With these animals what it tells me is that the prognosis for return to function for that leg, even if I fix the fix the fractures is really lower.


OK, so boom out of that one picture a lot of information. Horner's syndrome. Here's a nice little mnemonic. I remember the thing about brachial plexus avulsion. And off we go. Last thing, dogs in practice, sometimes you'll see a dog show up with Horner's and no other signs. There's no Titus, there's no trauma. We don't know what causes those, they are just idiopathic, which is fancy Latin for doctors an idiot. And a lot of those idiopathic dogs with Horner's get better. Now in cats, if you've got Horner's is almost always and there's a reason you can point to.