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This guide is my subjective and opinionated guide to Year 3 Shelf exams based on mainly my experience as well as some things I have heard. I have no disclosures or affiliations with any of the companies whose resources I recommend.
A.) General Tips:
1. Track Order:
People always ask about track order and I’ll be frank. Shelf exam questions are written so that prior shelf experience will help. This is especially true for IM, Surgery, and Family Medicine and you'll see numerous accounts on here of people taking these first vs. last and the discrepancy in difficulty. Sometimes, the criteria for honors at your school will be a set score and will not take this into account.
2. Core Resources: UWorld & OnlineMedEd
After your shelf exams, you have CK. I'm a shameless fan of UWorld and I think you should have it done once before CK prep which mirrors my Step 1 advice. Get UWorld done once, it's a great resource for the boards and the wards. Speaking of the boards and the wards, OnlineMedEd is my second must-use. This is because Dr. Williams does a great job emphasizing clinical peals like what tests to order and he outlines conditions in an organized manner. I started watching these videos the last week before my IM shelf. Up to that point, I was stuck in Step 1 mode and reasoned through questions based off my pathophysiology knowledge and not my clinical knowledge. OnlineMedEd taught me how to pick up on patterns of presentations and I stopped missing question on MS after his lecture on it.
3. Study Habits:
Just like Step 1, shelf exams cannot be crammed for. Anything can be on it. We have a deceptive day off before shelf exams and on my first shelf, I tried spending that day trying to review everything, slept only 5 hours, and almost failed. Instead use that day as a light review day. Do a few questions, read outlines your classmates have made, and perhaps watch Dr. Emma Holliday’s high impact 2 hour clerkship reviews (google Emma Holliday Surgery, etc.). Definitely get plenty of sleep the day before and the day of the shelf. Treat every shelf like a board exam, not a school exam where you can spend an all-nighter with your laptop and some Redbull and blaze through it all. You need to study a bit every day! It is very reasonable to get through OnlineMedEd +UWorld if you work at a light, but consistent pace. IM is an exception because 1,300 Qs is a bit much. However, in order to get those last few points on shelves, you may want to read a review book that does a more comprehensive job. The review books may have key details about a disease or explain something differently that finally makes something click. For shelf exams like Neurology or Pediatrics, they’ll include very rare diseases that the shelf will ask a question or two about. These books are CaseFiles, Blueprints, and PreTest. Many members on here post CaseFilesx2, PreTest, OME, and UWorld...If you can do that, great. If not, you may want to pick your battles and consider studying ahead for shelves during chiller months. A final reason to not cram is because of something I call “cram-bias” which is where you learnt something from cramming yesterday and pigeon-hole yourself into seeing that disease while taking the shelf. On an unrelated note, keep your hobbies, especially your fitness ones. This will give you the energy to spend those extra two hours per day after rotations reading.
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B.) Shelf Specific Advice: (OnlineMedEd+UWorld unless stated) Note that First Aid for Step 2 CK has a section where they rate resources similar to Step 2. I thumbed through it and felt it was outdated and served as an advertisement for their own stuff.
OB/GYN: CaseFiles was a great overview. The questions are easy, but they build confidence and the explanations help with differentials. The uWISE questions were also important, but do them after UWorld gives you the basics. If you want to honor this one, UWorld + OME may not be enough.
Difficulty: 8/10 (but could have just been me and my first shelf bias)
Neurology: PreTest was great! Neurology is very detail-heavy. UWorld/OME do a good job with the foundation and PreTest is a minutiae question book that will get you those board relevant minutiae they like to ask. I would not really recommend BluePrints because with limited time, I don’t retain much by reading long books. I wasn’t impressed with CaseFiles here. Lastly, don’t be lazy and if you completely forgot about a condition, look it up in First Aid for Step 1!
Difficulty: 6/10. A pretty straight-forward, but moderately challenging shelf.
Psychiatry: First Aid for Psychiatry is just a good comprehensive First Aid book to read throughout. It was honestly the only source people told me to use and it worked. I heard Lange also has decent book. OME was released after my shelf so I can’t evaluate its utility, but it’s probably effective. Focus on timelines and criteria. In psychiatry, the criteria is taken more literally than you'd think and will help eliminate choices. That said, I would not recommend just reading the DSM as that’s too dry.
Difficulty: 2/10. Very Straightforward. Don’t go overboard, but if you’re not interested in Psych, feel free to use this time to get other things done during third year.
Internal Medicine: So, Step Up To Medicine is pretty thorough and organized. It has a large fan-base, but I believe it's too much with 1300+ UWorld questions to do. I think that this shelf is the prototypical shelf in that they pull out all the tricks (atypical presentations of bread/butter diseases, Step 1 minutiae, and zebras) and as a result, your performance is largely dependent on your test-taking skills as opposed to knowledge you develop during your IM rotation. Here more than ever, you will need to read rather than relying on ward knowledge. Unlike other rotations where I suggest auxiliary resources, I say just do your OME+UWorld (1300+ Qs) to keep your test-taking and clinical reasoning sharp. If you even get half the UWorld IM questions done, that’s good. You can finish them later if you’re intent on finishing them.
Difficulty: 8/10. I think your Step 1 skills/performance is the best predictor.
Family Medicine: No Uworld nor OME here! So there's In-Service Training exams on PDFs. They're like 200 Qs with a paragraph explanation. There are four of them I could find online (2012-2015). Use those for questions and for an auxiliary resource, I think Case Files is ideal as it was for OB/GYN as it covers the bread and butter effectively and walks through common presentations you’ll see on your shelf. Also, there are small things to use here and there. There’s lots of Pediatrics so use MedBullets to learn all the pediatric infection presentations/management. Read the Ambulatory Section of SUTM because there are tons of things like rotator cuff management which will help. Lastly, get a hold of the USPSTF guidelines because there'll likely be a few that you'll have to apply there. Know all the screening guidelines and anticipate curveballs (if you find a polyp on colonoscopy how often to screen and when exactly you screen for breast cancer) and also know all of the Asthma/CHF/COPD stages and corresponding treatments (CaseFiles does a good job with this). Also know antibiotics for common conditions, but know their back-ups in cases of allergies/etc.
Difficulty: 7/10, but could be a 10/10 if you have it first.
Elective: I used this time to finish IM UWorld and get a head start on other sections.
Pediatrics: So just like Neurology, this is a huge minutiae exam so my auxiliary book was PreTest! There’s lots of genetics/biochemistry. Like Internal Medicine, BRS is a favorite, but I would say it's too much to get through. Again, it wouldn't hurt to occasionally open up FA for Step 1 because you may need to know the details of those diseases. On my shelf they described a peripheral smear and wanted us to give the deficient enzyme.
Difficulty: 5/10, less trickery and more material.
Surgery: This is probably the toughest shelf to study for given the hours of surgery and given that it’s known as the infamous disguised medicine exam. Add the fact that Pediatrics (and OB/GYN to a lesser extent) is also fair game and you’ll see why it’s got a reputation. The auxiliary resource for this is Devirgilio's Surgery: A Clinically Based Review. The beauty of this book is they describe medical and surgical management and all the pathophysiology of cases and the 200 Qs in the back have lots of specialty-specific factoids that showed up on my shelf. A lot of people say this is a medicine exam and I can see why they say that, but there are differences. On a medicine exam, they’re more apt to ask you about the management of Lipoprotein Lipase. Also, if they give you a Pulmonary Embolism question, they may give you an EKG. On surgery, they won’t ask much about preventative drugs unless it’s a vascular question asking about Aspirin. If there’s a PE, it’ll likely be a few days after an operation. The perioperative setting is the bread and butter of this shelf so review all diseases from this perspective. For all surgeries, wind, water, walking diseases occurs, after cardiac surgery MIs are common, but they’ll probably ask a second level question and not that something is an MI. After CABG, necrotizing mediastinitis is a thing as are retroperitoneal hematomas with cardiac caths,. For GI Surgery, think malabsorption issues when you cut out parts of gut. Know you GI presentations like the symptomatic cholelithiasis to cholangitis spectrum, as well as what to do about them. DO NOT underestimate the importance of atelectasis. It's like the Staph of Infectious Disease, when in doubt and there's post-OP breathing issues, guess atelectasis unless there's signs that are specific to something else. Also, know why atelectasis happens. Also, UWorld is super heavy on trauma but the real test has some, but not in the same proportion as UWorld.
Difficulty: Depends on when you have it but I’d give this a 9/10 regardless because of the schedule during surgery and the potential breadth.
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C.) Strategies to Get Questions Right:
1. Know the beast: For Shelf exams, they're NEVER EVER going to give you acute pancreatitis as epigastric pain radiating to the back. Instead the clue will be hidden as a 400+ lipase, a dude binge drinking, or a pleural effusion. Shelf writers take illness scripts and then manipulate them to make them unrecognizable so that what's left is still technically acute pancreatitis, but it doesn't read like pancreatitis. Think of it as a pre-med who will dutifully report the data but out of order vs. a chief resident presenting to the attending. If they do give you epigastric pain radiating to the back, they'll ask something why it radiates to the back. Be aware of this while studying and take extra time to figure out how you can diagnose some common conditions if lots of the usual presentation is missing.
2. "So like.... is that a thing?": So with Shelf exams you may eventually develop a feeling after wrestling with a question and debating choices where you suddenly realize, B is the right answer. The reason for this I think is because behind every shelf/step question is a learning objective (credit goes to Dr. Williams of OME for saying this explicitly which made it sink in). Consequently, when you realize your answer choice is an application of a learning objective, things click and you feel confident enough to move on. What is a learning objective or "thing"? It's one of those things you may have heard your 1st/2nd year clinical lecturer/attending on rounds mention that you thought was useless or too obvious. It’s those little bubbles in the margins of test prep books that seem obvious like ruling out pregnancy with secondary amenorrhea or for treating the underlying cause for Anemia of Chronic Disease. These "things" are medical pearls handed down from clinicians who've taken 100s of board exams and know what they test. They may have seemed like useless tidbits back when learning about Pathophysiology/Step 1 but they're relevant now. Also, OME does a good job of hitting the main ones. So…when you see a person with COPD, Rheumatoid Arthritis, GERD, etc. and then they throw an Iron profile at you and ask you the next best step, look for Methotrexate and not Iron Supplementation because you manage Anemia of Chronic Disease by treating the underlying cause. That's a thing!
Also, on the flip side, avoid choosing crap that you've never heard of. If you don't know the answer, chances are you're missing something and don't just reason that you don't recognize the presentation so it must be something I have not learnt and choose something you can’t even pronounce. If you’re on surgery and they’re talking about a kid with Altered Mental Status and you see things you haven’t seen before like Caput Succundeum, don’t pick it, you’ll learn about that when you read about on newborn Pediatrics and it’s something a surgery exam will test. You’ve learnt most the relevant diseases while studying for Step 1...if something seems weird, it usually is a trap but of course there are exceptions… but if you don't know, it's better to guess with a familiar option.
3. Know what's relevant vs. a distractor. Whether it's a bilaterally absent ankle reflex or a "grade 2 systolic murmur" learn to identify these as distractors because otherwise you'll fixate and try to make sense of them and it'll lead you down a rabbit hole of nonsense and sap valuable minutes off your time or make you choose a wrong answer. Many things cause sub-grade 3 systolic murmurs like dehydration or mild and old age can cause diminished ankle reflex. On the other hand, know that relevant heart sounds for the shelf exam are always KEY (diastolic, >grade 3, increase with inspiration+IVDU, or for Peds increase while standing up). The reason they do this is to go after physiology and clinical medicine simultaneously. Another example of something you want to always pay attention to is labs. Never make a decision before you get to the labs and know albumin-calcium relationships, PTH-Ca-PO4 (primary, secondary, tertiary PTH), K-Mg (correct one before the other), so those don’t trick you either.
4. Prime yourself for questions: I also got this from OnlineMedEd so credit goes to Dr. Williams but prime yourself for Questions by ALWAYS reading the last sentences and SKIMMING the choices FIRST. No need to highlight the question because it just requires a quick glance. No need to read the all the choices, just glimpse to get a gestalt on what the questions targeting. That way, when you read the paragraph long stem, you're primed to slice through all fat and slow down when you get to stuff that will differentiate between choice caput succandeum v. cephalohematoma (crossing suture lines). This is even more relevant when there’s a long stem and then the answer choices are a series of PTH-Ca-Vit-D or ABG permutations. By the way, if there’s an ABG given and the choices are metabolic alkalosis, acidosis, etc. all you need is the ABG data and Winter’s Formula for compensation. Use the stem (aspirin intoxication, heroin intoxication, DKA, panic attack) as a confirmation. NO, this is NOT an unorthodox strategy. Ask around and you'll be surprised how many people do this, but have kept it to themself.
A.) General Tips:
1. Track Order:
People always ask about track order and I’ll be frank. Shelf exam questions are written so that prior shelf experience will help. This is especially true for IM, Surgery, and Family Medicine and you'll see numerous accounts on here of people taking these first vs. last and the discrepancy in difficulty. Sometimes, the criteria for honors at your school will be a set score and will not take this into account.
2. Core Resources: UWorld & OnlineMedEd
After your shelf exams, you have CK. I'm a shameless fan of UWorld and I think you should have it done once before CK prep which mirrors my Step 1 advice. Get UWorld done once, it's a great resource for the boards and the wards. Speaking of the boards and the wards, OnlineMedEd is my second must-use. This is because Dr. Williams does a great job emphasizing clinical peals like what tests to order and he outlines conditions in an organized manner. I started watching these videos the last week before my IM shelf. Up to that point, I was stuck in Step 1 mode and reasoned through questions based off my pathophysiology knowledge and not my clinical knowledge. OnlineMedEd taught me how to pick up on patterns of presentations and I stopped missing question on MS after his lecture on it.
3. Study Habits:
Just like Step 1, shelf exams cannot be crammed for. Anything can be on it. We have a deceptive day off before shelf exams and on my first shelf, I tried spending that day trying to review everything, slept only 5 hours, and almost failed. Instead use that day as a light review day. Do a few questions, read outlines your classmates have made, and perhaps watch Dr. Emma Holliday’s high impact 2 hour clerkship reviews (google Emma Holliday Surgery, etc.). Definitely get plenty of sleep the day before and the day of the shelf. Treat every shelf like a board exam, not a school exam where you can spend an all-nighter with your laptop and some Redbull and blaze through it all. You need to study a bit every day! It is very reasonable to get through OnlineMedEd +UWorld if you work at a light, but consistent pace. IM is an exception because 1,300 Qs is a bit much. However, in order to get those last few points on shelves, you may want to read a review book that does a more comprehensive job. The review books may have key details about a disease or explain something differently that finally makes something click. For shelf exams like Neurology or Pediatrics, they’ll include very rare diseases that the shelf will ask a question or two about. These books are CaseFiles, Blueprints, and PreTest. Many members on here post CaseFilesx2, PreTest, OME, and UWorld...If you can do that, great. If not, you may want to pick your battles and consider studying ahead for shelves during chiller months. A final reason to not cram is because of something I call “cram-bias” which is where you learnt something from cramming yesterday and pigeon-hole yourself into seeing that disease while taking the shelf. On an unrelated note, keep your hobbies, especially your fitness ones. This will give you the energy to spend those extra two hours per day after rotations reading.
------------------------------------------------------------------------------------------------
B.) Shelf Specific Advice: (OnlineMedEd+UWorld unless stated) Note that First Aid for Step 2 CK has a section where they rate resources similar to Step 2. I thumbed through it and felt it was outdated and served as an advertisement for their own stuff.
OB/GYN: CaseFiles was a great overview. The questions are easy, but they build confidence and the explanations help with differentials. The uWISE questions were also important, but do them after UWorld gives you the basics. If you want to honor this one, UWorld + OME may not be enough.
Difficulty: 8/10 (but could have just been me and my first shelf bias)
Neurology: PreTest was great! Neurology is very detail-heavy. UWorld/OME do a good job with the foundation and PreTest is a minutiae question book that will get you those board relevant minutiae they like to ask. I would not really recommend BluePrints because with limited time, I don’t retain much by reading long books. I wasn’t impressed with CaseFiles here. Lastly, don’t be lazy and if you completely forgot about a condition, look it up in First Aid for Step 1!
Difficulty: 6/10. A pretty straight-forward, but moderately challenging shelf.
Psychiatry: First Aid for Psychiatry is just a good comprehensive First Aid book to read throughout. It was honestly the only source people told me to use and it worked. I heard Lange also has decent book. OME was released after my shelf so I can’t evaluate its utility, but it’s probably effective. Focus on timelines and criteria. In psychiatry, the criteria is taken more literally than you'd think and will help eliminate choices. That said, I would not recommend just reading the DSM as that’s too dry.
Difficulty: 2/10. Very Straightforward. Don’t go overboard, but if you’re not interested in Psych, feel free to use this time to get other things done during third year.
Internal Medicine: So, Step Up To Medicine is pretty thorough and organized. It has a large fan-base, but I believe it's too much with 1300+ UWorld questions to do. I think that this shelf is the prototypical shelf in that they pull out all the tricks (atypical presentations of bread/butter diseases, Step 1 minutiae, and zebras) and as a result, your performance is largely dependent on your test-taking skills as opposed to knowledge you develop during your IM rotation. Here more than ever, you will need to read rather than relying on ward knowledge. Unlike other rotations where I suggest auxiliary resources, I say just do your OME+UWorld (1300+ Qs) to keep your test-taking and clinical reasoning sharp. If you even get half the UWorld IM questions done, that’s good. You can finish them later if you’re intent on finishing them.
Difficulty: 8/10. I think your Step 1 skills/performance is the best predictor.
Family Medicine: No Uworld nor OME here! So there's In-Service Training exams on PDFs. They're like 200 Qs with a paragraph explanation. There are four of them I could find online (2012-2015). Use those for questions and for an auxiliary resource, I think Case Files is ideal as it was for OB/GYN as it covers the bread and butter effectively and walks through common presentations you’ll see on your shelf. Also, there are small things to use here and there. There’s lots of Pediatrics so use MedBullets to learn all the pediatric infection presentations/management. Read the Ambulatory Section of SUTM because there are tons of things like rotator cuff management which will help. Lastly, get a hold of the USPSTF guidelines because there'll likely be a few that you'll have to apply there. Know all the screening guidelines and anticipate curveballs (if you find a polyp on colonoscopy how often to screen and when exactly you screen for breast cancer) and also know all of the Asthma/CHF/COPD stages and corresponding treatments (CaseFiles does a good job with this). Also know antibiotics for common conditions, but know their back-ups in cases of allergies/etc.
Difficulty: 7/10, but could be a 10/10 if you have it first.
Elective: I used this time to finish IM UWorld and get a head start on other sections.
Pediatrics: So just like Neurology, this is a huge minutiae exam so my auxiliary book was PreTest! There’s lots of genetics/biochemistry. Like Internal Medicine, BRS is a favorite, but I would say it's too much to get through. Again, it wouldn't hurt to occasionally open up FA for Step 1 because you may need to know the details of those diseases. On my shelf they described a peripheral smear and wanted us to give the deficient enzyme.
Difficulty: 5/10, less trickery and more material.
Surgery: This is probably the toughest shelf to study for given the hours of surgery and given that it’s known as the infamous disguised medicine exam. Add the fact that Pediatrics (and OB/GYN to a lesser extent) is also fair game and you’ll see why it’s got a reputation. The auxiliary resource for this is Devirgilio's Surgery: A Clinically Based Review. The beauty of this book is they describe medical and surgical management and all the pathophysiology of cases and the 200 Qs in the back have lots of specialty-specific factoids that showed up on my shelf. A lot of people say this is a medicine exam and I can see why they say that, but there are differences. On a medicine exam, they’re more apt to ask you about the management of Lipoprotein Lipase. Also, if they give you a Pulmonary Embolism question, they may give you an EKG. On surgery, they won’t ask much about preventative drugs unless it’s a vascular question asking about Aspirin. If there’s a PE, it’ll likely be a few days after an operation. The perioperative setting is the bread and butter of this shelf so review all diseases from this perspective. For all surgeries, wind, water, walking diseases occurs, after cardiac surgery MIs are common, but they’ll probably ask a second level question and not that something is an MI. After CABG, necrotizing mediastinitis is a thing as are retroperitoneal hematomas with cardiac caths,. For GI Surgery, think malabsorption issues when you cut out parts of gut. Know you GI presentations like the symptomatic cholelithiasis to cholangitis spectrum, as well as what to do about them. DO NOT underestimate the importance of atelectasis. It's like the Staph of Infectious Disease, when in doubt and there's post-OP breathing issues, guess atelectasis unless there's signs that are specific to something else. Also, know why atelectasis happens. Also, UWorld is super heavy on trauma but the real test has some, but not in the same proportion as UWorld.
Difficulty: Depends on when you have it but I’d give this a 9/10 regardless because of the schedule during surgery and the potential breadth.
--------------------------------------------------------------------------------------------------------------
C.) Strategies to Get Questions Right:
1. Know the beast: For Shelf exams, they're NEVER EVER going to give you acute pancreatitis as epigastric pain radiating to the back. Instead the clue will be hidden as a 400+ lipase, a dude binge drinking, or a pleural effusion. Shelf writers take illness scripts and then manipulate them to make them unrecognizable so that what's left is still technically acute pancreatitis, but it doesn't read like pancreatitis. Think of it as a pre-med who will dutifully report the data but out of order vs. a chief resident presenting to the attending. If they do give you epigastric pain radiating to the back, they'll ask something why it radiates to the back. Be aware of this while studying and take extra time to figure out how you can diagnose some common conditions if lots of the usual presentation is missing.
2. "So like.... is that a thing?": So with Shelf exams you may eventually develop a feeling after wrestling with a question and debating choices where you suddenly realize, B is the right answer. The reason for this I think is because behind every shelf/step question is a learning objective (credit goes to Dr. Williams of OME for saying this explicitly which made it sink in). Consequently, when you realize your answer choice is an application of a learning objective, things click and you feel confident enough to move on. What is a learning objective or "thing"? It's one of those things you may have heard your 1st/2nd year clinical lecturer/attending on rounds mention that you thought was useless or too obvious. It’s those little bubbles in the margins of test prep books that seem obvious like ruling out pregnancy with secondary amenorrhea or for treating the underlying cause for Anemia of Chronic Disease. These "things" are medical pearls handed down from clinicians who've taken 100s of board exams and know what they test. They may have seemed like useless tidbits back when learning about Pathophysiology/Step 1 but they're relevant now. Also, OME does a good job of hitting the main ones. So…when you see a person with COPD, Rheumatoid Arthritis, GERD, etc. and then they throw an Iron profile at you and ask you the next best step, look for Methotrexate and not Iron Supplementation because you manage Anemia of Chronic Disease by treating the underlying cause. That's a thing!
Also, on the flip side, avoid choosing crap that you've never heard of. If you don't know the answer, chances are you're missing something and don't just reason that you don't recognize the presentation so it must be something I have not learnt and choose something you can’t even pronounce. If you’re on surgery and they’re talking about a kid with Altered Mental Status and you see things you haven’t seen before like Caput Succundeum, don’t pick it, you’ll learn about that when you read about on newborn Pediatrics and it’s something a surgery exam will test. You’ve learnt most the relevant diseases while studying for Step 1...if something seems weird, it usually is a trap but of course there are exceptions… but if you don't know, it's better to guess with a familiar option.
3. Know what's relevant vs. a distractor. Whether it's a bilaterally absent ankle reflex or a "grade 2 systolic murmur" learn to identify these as distractors because otherwise you'll fixate and try to make sense of them and it'll lead you down a rabbit hole of nonsense and sap valuable minutes off your time or make you choose a wrong answer. Many things cause sub-grade 3 systolic murmurs like dehydration or mild and old age can cause diminished ankle reflex. On the other hand, know that relevant heart sounds for the shelf exam are always KEY (diastolic, >grade 3, increase with inspiration+IVDU, or for Peds increase while standing up). The reason they do this is to go after physiology and clinical medicine simultaneously. Another example of something you want to always pay attention to is labs. Never make a decision before you get to the labs and know albumin-calcium relationships, PTH-Ca-PO4 (primary, secondary, tertiary PTH), K-Mg (correct one before the other), so those don’t trick you either.
4. Prime yourself for questions: I also got this from OnlineMedEd so credit goes to Dr. Williams but prime yourself for Questions by ALWAYS reading the last sentences and SKIMMING the choices FIRST. No need to highlight the question because it just requires a quick glance. No need to read the all the choices, just glimpse to get a gestalt on what the questions targeting. That way, when you read the paragraph long stem, you're primed to slice through all fat and slow down when you get to stuff that will differentiate between choice caput succandeum v. cephalohematoma (crossing suture lines). This is even more relevant when there’s a long stem and then the answer choices are a series of PTH-Ca-Vit-D or ABG permutations. By the way, if there’s an ABG given and the choices are metabolic alkalosis, acidosis, etc. all you need is the ABG data and Winter’s Formula for compensation. Use the stem (aspirin intoxication, heroin intoxication, DKA, panic attack) as a confirmation. NO, this is NOT an unorthodox strategy. Ask around and you'll be surprised how many people do this, but have kept it to themself.
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