The five most difficult areas of the Emergency Medicine Boards are usually going to be the five areas that you spent the least time reviewing, reviewed in the most distant period, or that you just never quite understood. If there is an area with which you have always had trouble, your success in this area is not going to improve unless you have put the time in to alleviate the difficulty. As you study, take advantage of the fact that some material just follows you from the beginning to the end of your medical career. Add these questions from your problem areas to the top of your list, and hit one or two questions in this region every day. Though we are discussing what we have called the most difficult areas below, the most difficult area is really a customized entity for each individual.
- Opthalmological disorders and emergencies are at the top of the “difficult” lists of many. Many don’t see or treat a lot of subacute opthalmologic disorders, though this content has a firm place on the boards. Know the symptoms, opthalmological exam, and method of treating the following: retinal artery occlusion, papilloedema, corneal ulceration (pseudomonas being the most common causative organism), hypopyon, pterygium, retinal detachment (review the way it looks on ultrasound (US)) and the normal parameters of intraoccular pressure (nl IOP = 10-21). Don’t ignore the IOP associations with open and closed angle glaucoma.
- Don’t forget the spinal cord injuries. Thankfully, this is another example of a time-honored area of which we do not see a lot in clinical practice. As a result, one often remembers to look over the spinal cord lesions and the corresponding anatomical area, but forgets to review the the mechanisms of injury. For instance, the hangman’s fracture is the result of a hyperextension injury, not a flexion injury. Make a chart and memorize whether associated symptomatology is anterolateral or contralateral for anterior cord, central cord, and Brown Sequard syndromes.
- Fractures and compartment syndromes are difficult to remember if not reviewed. Memorize the nicknames for the most common fractures and the associated nerves that may be damaged. The compartment syndromes of the leg are easy fodder for board exams. There are four compartments. Material related to the anterior compartment syndrome is often chosen. Normal compartment pressures in a normotensive adult should be less than 30. Know the four compartments of the leg, the nerves associated with each of these compartments, and the associated signs with damage to each of these nerves.
- There will be some tough CT and US reads on the exam, especially if they are unanticipated. Let’s go from top to bottom. Don’t miss the pontine hemorrhage with its associated pinpoint pupils. Review aortic dissection and know that it may be suggested by what may looks like a whiff of contrast extravasation. Don’t forget to review the ultrasound/clinical differences between cholelithiasis, choledocholithiasis, and cholecystitis. Be familiar with the normal radiographic appearance of the uterus and adnexa and how they look when an ovary is torsed, when there is a pregnancy in the tubes, or when there is a molar pregnancy. Know what a testicular torsion looks like, the time course of necessary intervention (you have not more than 6 hours), and be able to correlate laboratory values with corresponding US values. With each of these entities, be prepared to address treatment.
- Finally, we wanted to highlight three short, Isolated miscellaneous grab bag items. (1) Do not overlook the acute care of the hypothermic patient: general hypothermia and frostbite of the limbs and digits. (2) Know how to diagnose and treat both anterior and posterior urethral injuries. Do not put a foley in someone with blood at the urethral meatus. (3) And don’t forget dental emergencies. (You have 60 minutes to get an avulsed tooth back in :).
If you’d like some additional Emergency Medicine board practice questions around these topics (and many more), visit us at boardvitals.com.