Surgery EOR Key Concepts and Clinical Focus
Pre-Operative Risk Assessment and Optimization
Success on the Surgery EOR begins with understanding the physiological demands of anesthesia and surgical trauma. A significant portion of the exam focuses on the Revised Cardiac Risk Index (RCRI) and the identification of patients who require further cardiac or pulmonary clearance before entering the operating room. Candidates must be able to identify which medications to hold—such as ACE inhibitors or specific anticoagulants—and which to continue, like beta-blockers, to prevent intraoperative instability. Metabolic optimization is equally critical; for instance, understanding that a hemoglobin A1c above 7-8% or a serum albumin level below 3.0 g/dL significantly increases the risk of surgical site infections and poor wound healing. You will likely encounter questions regarding the timing of preoperative antibiotics, typically required within 60 minutes of the initial incision, and the specific selection of agents based on the surgical site (e.g., Cefazolin for skin vs. Cefotetan for colorectal procedures).
Recognizing and Managing Post-Operative Complications
Post-operative care is frequently tested through the lens of the "5 Ws" of post-op fever: Wind (atelectasis/pneumonia), Water (UTI), Walking (DVT/PE), Wound (infection), and Wonder drugs. The Surgery EOR high yield topics focus heavily on the timing of these complications. For example, a fever within the first 24 hours is often atelectasis or a pre-existing infection, whereas a fever on post-op day 5 to 7 suggests a surgical site infection or a deep venous thrombosis. You must also master the management of post-operative ileus versus a mechanical small bowel obstruction. The exam will expect you to recognize the clinical signs of an anastomotic leak—tachycardia, abdominal pain, and leukocytosis—following GI surgery. Furthermore, fluid and electrolyte management is paramount; being able to calculate maintenance fluids using the 4-2-1 rule and recognizing the signs of hypocalcemia following a thyroidectomy are standard assessment points.
Surgical Presentations of the Acute Abdomen
The ability to differentiate between surgical and non-surgical abdominal pain is a cornerstone of this exam. You must be proficient in identifying classic physical exam findings such as McBurney’s point tenderness, the Rovsing sign, and the Murphy sign. The EOR often presents vignettes where you must decide the most appropriate next step in management: is it an immediate surgical consultation, an ultrasound, or a CT scan with IV contrast? Understanding the pathophysiology of conditions like acute cholecystitis, appendicitis, and perforated peptic ulcers is vital. For instance, in a patient with suspected mesenteric ischemia, the exam may look for your knowledge of the "pain out of proportion to exam" triad. You should also be familiar with the indications for emergent laparotomy versus laparoscopic approaches and the specific criteria used to grade the severity of pancreatitis, such as the Ranson Criteria, which dictates the level of inpatient care required.
Pediatrics EOR: Growth, Development, and Common Illnesses
Utilizing Developmental Milestones in Assessment
The Pediatrics EOR study guide must center on the timeline of human growth, as developmental milestones provide the framework for pediatric questions. You are expected to know the specific ages at which children should achieve motor, language, and social benchmarks. For example, a child should be able to sit without support by 6 months, walk independently by 12 to 15 months, and speak in two-word sentences by age 2. The exam often uses these milestones to test for developmental delays or to set the stage for a clinical presentation. If a 9-month-old cannot perform a pincer grasp, it is a significant clinical finding. Furthermore, understanding the progression of primitive reflexes, such as the Moro or Palmar grasp, and when they should disappear (typically by 4 to 6 months) is a frequent point of assessment. Growth chart interpretation, specifically recognizing a "crossing of percentiles" as a sign of failure to thrive, is a fundamental skill for this rotation.
Age-Based Pharmacology and Vaccination Schedules
Pediatric medicine requires a precise approach to pharmacology, where dosing is almost always weight-based (mg/kg). The exam tests your ability to calculate correct dosages and recognize medications that are contraindicated in certain age groups, such as the avoidance of tetracyclines in children under 8 due to tooth discoloration or aspirin due to the risk of Reye Syndrome. Equally important is the CDC immunization schedule. You must know which vaccines are live-attenuated (MMR, Varicella) and therefore contraindicated in immunocompromised patients. Expect questions on the timing of the primary vaccine series, such as the 2, 4, and 6-month requirements for DTaP, Hib, and IPV. Understanding the difference between a normal vaccine reaction and a true contraindication—like encephalopathy within 7 days of a previous DTaP dose—is a high-level concept that distinguishes top-performing candidates.
Diagnosis and Management of Common Pediatric Infections
Infectious disease in pediatrics is often age-dependent, and the EOR reflects this by testing specific pathogens associated with different age brackets. For neonates with fever, you must know the common culprits: Group B Streptococcus, E. coli, and Listeria monocytogenes. In older children, the focus shifts to viral illnesses like bronchiolitis (RSV) and croup (Parainfluenza). The exam will ask you to identify the steeple sign on a neck X-ray for croup versus the thumbprint sign for epiglottitis. Management of Otitis Media is another staple; you must know the first-line treatment (Amoxicillin) and the criteria for observation versus antibiotic therapy. Additionally, the EOR tests your ability to differentiate pediatric exanthems. Distinguishing the "slapped cheek" appearance of Erythema Infectiosum (Fifth Disease) from the "sandpaper rash" of Scarlet Fever is essential for accurate diagnosis and management planning.
Psychiatry EOR: Diagnosis, Pharmacology, and Risk
Applying DSM-5 Criteria to Clinical Vignettes
The Psychiatry EOR exam review is heavily weighted toward the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). You must be able to differentiate between similar presentations based on the duration of symptoms. For instance, Schizophreniform disorder is diagnosed when symptoms last between one and six months, whereas Schizophrenia requires symptoms for more than six months. Similarly, in mood disorders, you must distinguish between Major Depressive Disorder (MDD) and Persistent Depressive Disorder (Dysthymia) based on the two-year timeframe for the latter. The exam frequently uses vignettes to test your ability to identify the "SIGECAPS" criteria for depression or the "DIGFAST" criteria for a manic episode. Precision is key; the presence of even one manic episode is sufficient for a diagnosis of Bipolar I, while Bipolar II requires at least one hypomanic episode and one major depressive episode without any history of mania.
First-Line Pharmacotherapy and Side Effect Monitoring
Pharmacology in psychiatry focuses on the mechanism of action and the adverse effect profiles of psychotropic medications. Selective Serotonin Reuptake Inhibitors (SSRIs) are typically first-line for both anxiety and depressive disorders, but you must be aware of their side effects, such as sexual dysfunction and weight gain. The exam will likely test your knowledge of Neuroleptic Malignant Syndrome (NMS) versus Serotonin Syndrome; NMS is characterized by "lead-pipe" rigidity and elevated creatine kinase, often due to antipsychotics, while Serotonin Syndrome presents with hyperreflexia and myoclonus. You should also be familiar with the monitoring requirements for specific drugs, such as the need for regular CBCs to check for agranulocytosis in patients taking Clozapine, or the monitoring of lithium levels to prevent toxicity, which can manifest as tremors, ataxia, and nephrogenic diabetes insipidus.
Conducting a Suicidality and Danger Assessment
Safety is the highest priority in psychiatric practice and on the EOR. You must be able to perform a thorough suicide risk assessment, identifying static risk factors (male gender, previous attempts) and dynamic risk factors (active substance use, hopelessness, access to firearms). The exam often asks for the next best step when a patient expresses suicidal ideation: does the patient require voluntary or involuntary hospitalization (e.g., a 72-hour hold)? Understanding the legal and ethical obligations of the Duty to Warn (Tarasoff Rule) is also critical. If a patient expresses a specific threat toward an identifiable individual, the clinician has a legal mandate to protect that person. Furthermore, you must recognize the signs of domestic violence and child abuse, as PAs are mandatory reporters. Assessment of the patient’s "insight" and "judgment" during the Mental Status Exam (MSE) provides the clinical basis for these safety determinations.
Internal Medicine EOR: Complex Diagnostics and Chronic Disease
Building a Broad Differential for Vague Symptoms
The Internal Medicine EOR differentials section tests your ability to synthesize multi-system information. When presented with a vague symptom like dyspnea, the exam expects you to consider cardiac (HF, MI), pulmonary (COPD, PE, pneumonia), and hematologic (anemia) causes simultaneously. You must use the patient’s history and physical exam to narrow this list. For example, the presence of paroxysmal nocturnal dyspnea and an S3 gallop strongly points toward heart failure, while pleuritic chest pain and calf swelling increase suspicion for a pulmonary embolism. The exam tests your ability to order and interpret the "initial" versus the "most definitive" test. While a chest X-ray might be the initial step for a patient with cough, a CT scan or a tissue biopsy may be required for a definitive diagnosis of lung cancer or interstitial lung disease. Mastery of acid-base disorders using the Winter’s Formula to determine respiratory compensation in metabolic acidosis is a common high-level assessment point.
Guideline-Directed Management of Chronic Conditions
Internal Medicine is governed by evidence-based guidelines, and the EOR reflects this. You must be current on the JNC 8 or ACC/AHA hypertension guidelines, the ADA standards for diabetes management, and the GOLD criteria for COPD. This includes knowing when to start a statin based on the ASCVD risk calculator and when to escalate therapy from Metformin to secondary agents like SGLT2 inhibitors or GLP-1 agonists, especially in patients with comorbid heart failure or chronic kidney disease. The exam also emphasizes the management of chronic heart failure with reduced ejection fraction (HFrEF), specifically the use of GDMT (Guideline-Directed Medical Therapy) involving ACE inhibitors/ARBs/ARNIs, beta-blockers, and aldosterone antagonists. Understanding the long-term monitoring of these conditions—such as tracking EGFR and albuminuria in diabetic patients—is essential for demonstrating competence in the longitudinal care of complex adults.
Inpatient Medicine: Sepsis, AKI, and Discharge Planning
A significant portion of the Internal Medicine EOR covers hospital-based care. You must be proficient in the early recognition of sepsis using the qSOFA score or SIRS criteria and the subsequent management with aggressive fluid resuscitation (30 mL/kg) and early broad-spectrum antibiotics. Acute Kidney Injury (AKI) is another core topic; you should be able to differentiate pre-renal, intrinsic, and post-renal causes using the Fractional Excretion of Sodium (FeNa). A FeNa of less than 1% typically indicates a pre-renal state, such as dehydration. The exam also touches on the logistics of inpatient care, including the prevention of hospital-acquired complications like DVT and pressure ulcers. Finally, discharge planning requires an understanding of the criteria for transitioning a patient to a skilled nursing facility (SNF) versus home health, ensuring a safe handoff to the outpatient setting to prevent 30-day readmissions.
Women's Health EOR: OB/GYN Integration
Routine Prenatal Care and High-Risk Pregnancy Signs
The Women's Health EOR balances routine obstetric care with the identification of life-threatening emergencies. You must know the schedule of prenatal visits and the specific screenings performed at each trimester, such as the glucose challenge test at 24-28 weeks and the Group B Strep swab at 35-37 weeks. High-yield topics include the differentiation of hypertensive disorders of pregnancy. Preeclampsia is defined by hypertension and proteinuria after 20 weeks of gestation, while Eclampsia involves the addition of seizures. You must also recognize the signs of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets). Management of these conditions often involves magnesium sulfate for seizure prophylaxis and timely delivery. Understanding the different stages of labor and the interpretation of fetal heart rate monitoring—specifically recognizing late decelerations as a sign of uteroplacental insufficiency—is critical for the obstetric portion of the exam.
Diagnosis and Management of Gynecologic Cancers and Infections
Gynecologic oncology and infectious disease are major components of the PA EOR key concepts by rotation. You must be familiar with the screening guidelines for cervical cancer using Pap smears and HPV testing, and the subsequent management of abnormal results based on the ASCCP algorithms. For ovarian cancer, the exam may focus on the vague abdominal symptoms and the role of the CA-125 marker in post-menopausal women. In the realm of infections, you must distinguish between Bacterial Vaginosis (clue cells, positive whiff test), Candidiasis (pseudohyphae, cottage cheese discharge), and Trichomoniasis (strawberry cervix, motile trichomonads). The treatment for Pelvic Inflammatory Disease (PID) is also high-yield, typically involving a combination of Ceftriaxone, Doxycycline, and potentially Metronidazole to cover polymicrobial flora and prevent long-term sequelae like infertility or ectopic pregnancy.
Contraceptive Options and Menopausal Symptom Management
Providing patient-centered counseling on reproductive health is a core competency. You must know the contraindications for estrogen-containing contraceptives, such as a history of migraine with aura, smoking over age 35, or a history of thromboembolism. The exam will test your knowledge of the efficacy and side effects of Long-Acting Reversible Contraception (LARC), such as IUDs and subdermal implants. Moving to the end of the reproductive lifespan, you must manage the symptoms of perimenopause and menopause. This includes understanding the indications and risks of Hormone Replacement Therapy (HRT). For a woman with an intact uterus, estrogen must always be paired with progestin to prevent endometrial hyperplasia and cancer. For those with only vasomotor symptoms who cannot take hormones, SSRIs or SNRIs are often tested as viable alternatives.
Emergency Medicine EOR: Acuity and Stabilization
'Can't Miss' Diagnoses for Common Complaints
In the Emergency Department, the priority is to rule out life-threatening conditions. The Emergency Medicine EOR requires you to maintain a high index of suspicion for "can't miss" diagnoses. For a patient with a headache, you must consider subarachnoid hemorrhage (the "thunderclap" headache) and know that if the CT is negative, a lumbar puncture is the next step to look for xanthochromia. For chest pain, the differential must include Tension Pneumothorax, Aortic Dissection, and Pulmonary Embolism alongside Acute Coronary Syndrome. You should be familiar with the Wells Criteria for PE and the HEART score for chest pain stratification. The exam tests your ability to act decisively; for instance, recognizing that a patient with a suspected tension pneumothorax needs immediate needle decompression before waiting for a chest X-ray.
ACLS Protocols and Trauma Assessment
Mastery of Advanced Cardiovascular Life Support (ACLS) is non-negotiable for this rotation. You must know the algorithms for ventricular fibrillation, pulseless ventricular tachycardia, asystole, and PEA. This includes the correct dosages of Epinephrine and Amiodarone, as well as the identification of reversible causes (the H's and T's). In trauma, the Primary Survey (Airway, Breathing, Circulation, Disability, Exposure) is the standard of care. You must be able to recognize the signs of cardiac tamponade (Beck’s Triad: muffled heart sounds, JVD, hypotension) and the management of a flail chest. Understanding the Glasgow Coma Scale (GCS) is also essential, as a score of 8 or less generally indicates the need for intubation to protect the airway. The EOR will often present a trauma scenario and ask for the sequence of interventions based on these established protocols.
Rapid Diagnostic Interpretation and Disposition Decision-Making
Emergency Medicine requires the rapid interpretation of diagnostic data to make disposition decisions. You must be able to read an EKG for signs of ST-segment elevation (STEMI), ischemia, or electrolyte imbalances like the peaked T-waves of hyperkalemia. Radiographic interpretation of the "FAST" exam (Focused Assessment with Sonography for Trauma) is also a common topic, specifically looking for free fluid in the Morison pouch or the splenorenal recess. Once the initial workup is complete, the exam tests your clinical judgment regarding disposition: does the patient require admission to the ICU, a telemetry floor, or can they be safely discharged with outpatient follow-up? For example, a patient with a stable kidney stone and controlled pain can be discharged, whereas a patient with a kidney stone and a concurrent UTI (obstructive uropathy) requires emergent urological intervention and admission.
Family Medicine EOR: Comprehensive Primary Care
Preventative Screening and Health Maintenance Across Lifespans
The Family Medicine EOR content focus is broad, emphasizing the United States Preventive Services Task Force (USPSTF) Grade A and B recommendations. You must know the ages at which to begin and end screenings for colon cancer (45-75), breast cancer (biennial mammograms 50-74), and lung cancer (annual low-dose CT for eligible smokers). This rotation also covers adult immunizations, such as the shingles vaccine (Shingrix) starting at age 50 and the pneumococcal series for those over 65 or with certain chronic conditions. The exam tests your ability to apply these guidelines to various patient scenarios, ensuring that you can manage a "well-visit" for a patient of any age. Understanding the role of the Annual Wellness Visit in identifying geriatric syndromes, such as frailty or cognitive impairment, is also a key component of the family medicine mindset.
Managing Multimorbidity in the Outpatient Setting
Unlike specialty rotations, Family Medicine involves managing multiple chronic conditions simultaneously. You might see a patient with hypertension, type 2 diabetes, and osteoarthritis in a single 15-minute encounter. The exam tests your ability to prioritize these issues and recognize how treatments for one may affect another—for example, the use of NSAIDs for arthritis exacerbating hypertension or chronic kidney disease. Polypharmacy is a major theme; you should be familiar with the Beers Criteria, which lists medications that should be avoided or used with caution in the elderly, such as diphenhydramine or long-acting benzodiazepines. The goal is to optimize the patient’s quality of life while minimizing the burden of treatment and the risk of adverse drug-drug interactions.
Differentiating Self-Limiting Illness from Requiring Specialist Referral
A primary role of the family practitioner is to act as a gatekeeper for specialized care. The EOR tests your ability to manage common outpatient complaints—such as upper respiratory infections, low back pain, or minor rashes—while identifying the "red flags" that necessitate a referral. For instance, most acute low back pain is musculoskeletal and resolves with conservative care, but the presence of "saddle anesthesia" or fecal incontinence suggests Cauda Equina Syndrome, requiring emergent neurosurgical referral. Similarly, while a family PA can manage most cases of uncomplicated GERD, the presence of alarm symptoms like weight loss or dysphagia warrants a referral for an upper endoscopy. Knowing when to treat and when to refer is a fundamental skill that demonstrates your understanding of the scope of primary care medicine.