I passed all sections as well. I have a few thoughts on preparation as well as test-taking strategy.
Preparing for Multiple Choice: The single best preparation you can do is pay attention during surgery and show up for cases prepared. This will have you actively thinking and the subject becomes more than an academic exercise for you. The more you do this over 3 years, the less important it is to do practice questions.
I used boards by numbers for practice questions. I found the study notes unhelpful. It's good as a question bank in terms of directing you to subject areas where you are weak, but BBN is also outdated (too many questions about arthrograms) and overemphasizes eponyms and classification schemes. In any case, I found the multiple choice questions much harder on the exam (especially the RRA questions) then on BBN or the ABFAS practice exam or in-training exams. A colleague of mine used board vitals and I saw a few of their practice questions which were also pretty dumb.
Which Brings me to the Simulation Exam: This exam attempts but ultimately falls short of being a realistic patient scenario. While it's understandable why we would limit the examination to 10 maneuvers, certain presentations may have a broad differential dx and certain diagnoses require a thorough PE workup (e.g. Flatfoot recon). Personally, I think 15-20 maneuvers is a better allowance. My biggest issue is that in a real world scenario, you have the ability to ask the patient to point with one finger where it hurts, but we can't here (there's a way around this, see below under imaging). So clearly, the objective here is not to do what's best for your simulated patient but to optimize your score. The good news is that the test can be outwitted.
Imaging: This was the first tab I would go to when I was taking the test. In many cases, pinpointing the symptoms is unavailable from the history, but an MRI will automatically give the 2-3 slices with all the diagnostic information you need. I have to respectfully disagree with
@Ankle Breaker about the shotgun strategy, because not only has ABFAS explicitly stated they will not penalize you for unnecessary studies, but shotgunning your imaging often ensures you maximize your diagnostic information and therefore your exam score. While I was sitting for the exam, I remember thinking on one case, "Sure I'll get a CT scan, even though I don't think it's necessary." Turned out CT images were available, though I'm not sure this equates to the scan being a graded point. While ridiculous, this "MRI first and ask questions later" strategy ensures you can proceed efficiently through the case. The best part is that you're allowed 10 imaging studies, so it's hard to imagine a scenario where you would hit that limit.
PE: Here's where you trade your shotgun for a sniper rifle. From the grading rubric for the ABFAS practice exam, it would seem that checking pedal pulses and sensation [syntax: "light touch"] are not graded points. Still, I think it's appropriate to do. Most of the time asking for "vitals" gets you all the vital statistics you need on an infected pt, though sometimes you'll get the dreaded "be more specific" which in my opinion should not deduct from your 10 maneuver allowance. Remember, use your imaging findings to direct your exam, which we obviously do not do in real life but remember, this is about maximizing points, and if they didn't want us to use this approach they wouldn't allow is to switch freely between the imaging and PE tabs. I almost always used 8-10 maneuvers, even though only 3 of them are graded for points.
Other PE pearls:
1) check for crepitus and lymph nodes on infection cases
2) ALWAYS range the ankle joint and follow it with a Silfverskiold exam if necessary. The equinus workup/dx/management can lead to massive point loss if you forget it.
3) Flatfoot: there are a lot of specific maneuvers here that add up to big points. Heel raise, hubscher maneuver, RCSP, palpating the sinus tarsi.
Labs: I shotgunned labs too. While I'm 90% sure this is not necessary, I would get routine preoperative labs on everyone. CBC, PT/INR. Vitamin D levels are also a nice touch, but I doubt a graded point. For some idiotic reason, BMP/CMP are not on the menu. Type "serum" and then pick off the individual electrolytes. Obtaining serum creatinine would theoretically have ramifications on the use of IV contrast in your imaging, but ABFAS kindly glosses over this issue within the confines of the simulation. All diabetic patients get fingersticks and HbA1c, all RA pts get ESR/CRP, ditto for infections plus blood cx and wound cx, alcoholics gets AST/ALT, and anyone where we have gout in the differential gets a UA. For the ladies, hCG. You have up to 20 choices, so the world is your oyster under this tab. Practice the simulation online and you can get your whole lab panel clicked off in under a minute.
Diagnostic Procedures: Careful here, because some of these procedures are more invasive and the potential to lose points exists. Wounds need to be probed [syntax "wound probe"]. Smokers and others with lousy pulses should get Dopplers, though that's never been a graded point on the practice test. Diagnostic blocks are easy points to add in any case involving nerve entrapment or arthritis. EMG for tarsal tunnel cases. For serious trauma cases, check compartment pressures. Soft tissue masses should be transilluminated, aspiration bx, and followed by incisional/needle bx.
Diagnosis: Self-explanatory, but don't forget equinus! Half the patients will have it!
Management: See the ABFAS practice exam to get an idea what they're looking for. I think this was pretty straight-forward, if you were thorough in your workup and diagnosis, the treatment plan follows logically. Make sure you know proper syntax, for instance you don't "consult" vascular, you "refer" to vascular. Finally, when in doubt, fuse the joint.
