"Without performing a single calculation we have probably gleaned enough information in just a minute or two to write an answer that would have passed this question."
A 23 year old male presents to your ED with a decreased level of consciousness. His arterial blood gas results are:
Did you see it?
It's right there at the bottom - a measured osmolality.
If you're observant, and you think about WHY the question has been put together the way it has, there's only one conclusion you can come to. The measured osmolality is there to help you calculate an osmolar gap. That's the only reason to put it in there.
So, thinking for a moment about this, there are only a couple of ABG type questions that cause a rise in the osmolar gap - methanol and ethanol poisoning. Both of these would fit with the patient's presentation, and are the likely diagnosis. In fact, it's almost possible to reverse engineer an entire answer to the question above from this one observation. (For example, we know there has to be a RAGMA with a high lactate.)
We can also be more specific again and reinterpret what we now know in light of the other information we've been given. If you are observant for just a minute again, you'll see that the patient has normal renal function, which differentiates methanol toxicity from ethanol toxicity.
Without performing a single calculation we have probably gleaned enough information in just a minute or two to write an answer that would have passed this question.
That's only a small example of what we do at fellowshipexam.com. We spend 26 weeks putting our candidates through their paces. We've just had our first face to face meeting where we spent a large amount of time dissecting questions. Understanding the "how" and "why" of a question is just as important as knowing the "what".