DIP Episode 269 - NBME Ortho Series 1: Bone Tumors

Okay, welcome. My name is Divine. This is a piece of 269 of the Divine Intervention Podcast. And in this podcast, I'll be talking about some orthopedic pathologies that are classically tested on the USML exams. Basically, I'm going to be making ortho podcasts and they're going to have like specific themes, right? The theme for this one, this one I'm going to be talking about today at the Bone Tumors, right? So these Bone Tumors, they are things that just shop a lot on me exams, right? And again, for whatever reason, people tend to struggle with this stuff. So it was just one of these things you kind of want to keep at the back of your mind, for example. So what if they give you a question about a patient and you know, they tell you that it's like a six-year-old girl, right? And they tell you that, or let's say six-year-old male because this condition is actually a lot more common in males. And they tell you that he has like this very severe, you know, very severe like pain in his lower femur, right? Or upper femur, right? And then they tell you that pain in upper femur worse at night, right? And then they tell you that, oh, it's better when he takes like Tylenol or something like that. If you see that, what should you be thinking about? I really hope you're thinking about an osteo-stuma, right? So remember, an osteo-stuma classically, it gets better, it's worse at night and it gets better when you consume enzymes, right?

But one thing I want to say is one thing your friends at the NBME love to conflict osteo-stuma's with is grain pains. And let me just tell you one very simple principle that will help you differentiate between those two. When people have an osteo-stuma, it's going to be a unilateral process, right? When people have grain pains, it's going to be a bilateral process. It's going to be the same presentation on your exam. Bumping that is worse at night gets better with NSAIDS. But if it's unilateral, it's going to be an osteo-stuma. If it's bilateral, it's going to be green pains, right? And the thing is you may see okay, divine, why does the pain get worse at night and people that have osteo-stuma? The reason behind that is you actually produce more prostate glandins at night, right? So the thing is it's that prostate glandin production that ultimately leads to the pain, right? And the key critical thing I remember is by giving an NSAID, which is a cycloxygenase inhibitor, you will no longer produce those prostate glandins and that will cut down on the child's pain, right? Now one thing that your friends at the NBME love to do is they love to see if you are able to associate some buzzword descriptions with a particular bone pathology, right? So the thing is you are not necessarily expected to be able to identify these pathologies on imaging, even if they provide imaging, it's not going to be critical to answering your question correctly.

But being able to look at the description and they provide and say, oh, this is what they are going after, it's actually a pretty useful room with ortho, especially on NBME exams. The thing is if they describe a bull's eye pattern on a radiograph, on a plain radiograph, then we are talking about an osteo-stuma again, especially if you find it like in the femur or in the tibia again in the right patient population, which will be a kid, right? Because essentially the reason it's a bull's eye is you basically see, if you look at this stuff on imaging, you basically see like a radio-lucent like mitus in the middle, right? That's like the bull's eye and then you have like a sclerotic bone surrounding it. So if you see that that's the classic presentation of an osteo-stuma. And then what did they give you a question about a child, right? And they tell you that this child has, you know, it's just getting imaging for some other reason, like this is like an incidental finding. And they find the, on a plain radiograph, they see like this soap bubble-like lidic lesion on the child's femur, for example. And they say nothing in the question about the child having any symptoms or anything. This is just like an incidental finding. And they don't give you any other clues. What should you be thinking about? I would really hope that you're picking the answer that says that the child has something called a fibroscortico defect. So fibroscortico defects, they actually usually symptomatic.

They're usually found incidentally, right? And again, they have this soap bubble pattern on plain radiographs. And they tend to be again, be found in the femur and the tibia. In fact, I'll tell you this, most bone problems on embankment exams, especially in kids, shopping the tibia and in the femur. That's something that I think will help you quite significantly on embankment exams. Now, what if they give you a question about a child and they tell you that, you know, this child doesn't really have any symptoms, right? Doesn't really have any symptoms doing pretty well. But again, as an incidental finding on imaging, they find like a mushroom-like defect on a plain radiograph of a bone, right? It can be like the femur, the tibia, the humerus. You find a mushroom-like defect. If you see this, what do you want to think about? I really hope that you're thinking about like an osteocondroma, okay? Think about an osteocondroma. The thing with osteocondroma is they look like mushrooms, right? So for people from not from the US, I mean, personally, for me, I don't eat mushrooms. And I feel like most, at least when I come from Nigeria, most people, I'd never saw anyone eat mushrooms ever in all my, like, 18 years in Nigeria. So, but I now know what a mushroom is. Obviously, I haven't lived here for a while. But basically, if you see like a mushroom-shaped lesion on bone in a kid, especially a male kid, I want you to think about an osteocondroma. Maybe like divine.

What's this mushroom coming from? Actually, pretty easy. The mushroom is actually basically like the head of the mushroom is like cartilage. That's why it's called osteocondroma, right? Condromines cartilage, right? So it's called an osteocondroma because it's almost like you have a bone lesion that is capped by cartilage, right? So that's the big thing to keep in mind with that. Now, what if they give you a question about a child? And they tell you that this child has like an asymptomatic, you know, again, just incidental loam, they find it on incidental imaging. And this can be something that can show up in the hand or you can show in the foot. So it tends to show up more like smaller bones, right? And they tell you that they find this lesion, right, has very sharp margins. But they tell you that it has a lot of like stippled calcifications or a lot of punk-tick calcifications or like pop, just basically imagine popcorn, right? Like a lot of popcorn-like calcifications, right? Like again, small bone, hand, foot, well circumscribed popcorn-like calcifications or they may use the word stippled or they may use the word punk-tick. If you see this, what do you want to think about? I really hope that you're thinking about an incondroma, right? An incondroma, an incondroma.

So again, let me summarize some of these findings I've described because again, it's just one of these things that are very high yield to know, for example, osteoarthritis, osteomas, bullseye pattern, very high yield, right? So you find radio loosened center and then dense clarity bone around it. That's the bullseye. Just basically imagine like that bullseye rash of lime disease, but think of it in the bone. That's going to be an osteoarthritis tumor for you. A fibrous corticode effect is a soap-like lesion. It's a bubble-like lesion, right? And you have like a well-defined cleratic margin, right? So you'll be like a soap, you'll be like soap bubbles, right? You'll be a lyrically lesion. And then osteocondromas look like mushrooms. That's the big thing when it keeps in mind. The top of the mushroom, the head of the mushroom, is the cardleach that is capping that bone lesion. And then an incondroma is going to be in small bones. It's going to be in the hand or in the foot or an embankment exam. It's going to be a well-struck conscribed and it's going to have a very specific distribution of castifications. You'll be like, let me use the word stippled or pontate or popcorn-like castifications. If you see that, then you absolutely want to think about an incondroma. Now, one unfortunate thing that can happen with an incondroma or an osteocondroma is that they can actually degenerate, right?

So what if they give you a question and detail you that, oh, this person that has it in incondroma or condroma or an osteocondroma, they tell you that this child suddenly starts having like very, like they've known that the lesion existed in the past. And then the child starts having like very severe pain around the side of the initial lesion. If you see that you absolutely, absolutely want to think about a condroma, right? Condroma is unfortunately if they're low grade, if they're low grade, you know, it's not a big deal. They're very treatable. But if you're high grade, that's bad, right? That's super, super bad, right? Like the survival rate is like 20 to 30, 40% of what they're about. It's actually pretty, pretty bad, a lesion. And one thing, one clue, one telltale sign on an MBME, that, oh, something like an incondroma has progressed to becoming a condroma, is you don't have those lesions being well-defined anymore. They're not going to be well-circumstcribed. They'll now be irregular. They'll be all over the place, right?

Because remember, when things are metastasizing, they don't try to like, oh, let's go in a straight line, let's, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no if you see any of those things, you want to be thinking about some kind of malignant bone lesion and what's the pathophysiology behind the carbon strangle really?

the pathophys is essentially you have cancer that is standing between, that is basically lifting the cortex of the bone like off of the surface of the bone right? so it's almost like you have this cancer that's standing as a go between between the bone and the cortex of the bone. so that causes the bone cortex like the periostom to lift off right? that's what's known as codaments that's what's known as codaments strangle so obviously we cannot talk about malignant bone lesions without talking about osteosircomas right? now an in-bim exams osteosircomas are very very high heel to no and the love to test risk factors in fact these things with risk factors most likely sites of metastasis those are things your friends at the in-bim love to go after with osteosircoma remember osteosircoma you can a person can get that if they have a history of retinoblastoma in childhood right? so they give you a question about a newborn that has a white reflex instead of a red reflex that child has a retinoblastoma that child having that red reflex I mean having that white reflex has the arbeginneutational retinoblastoma that increases the child's risk of getting an osteosircoma in the future and then another thing that can also predispose a person to having osteosircomas is if a person has a history of Pages disease right?

again Pages disease when a person has Pages disease they have like disordered bone formation the bone is very hyper metabolic that can predispose the person to ultimately getting an osteosircoma another thing that can predispose a person to get an osteosircoma on an in-bim exam is if they are taking this drug known as terryparatite right?

so we know that terryparatite is a drug that's used to treat osteoporosis on an in-bim is and if you're if you're wondering why the thing is terryparatite is basically a pth analog and pth kind of works like gnr in a sense if you give pth in a continuous fashion that's going to cause bone to be resolved but if you give pth in a pulsatile fashion that's actually going to cause bone to be built so when people take terryparatite so it's spelled as t-e-r-i-p-a-r-a-t-i-d-e terryparatite if people take terryparatite you essentially giving them a stimulating factor for a bone so again if you're giving something that causes like uncontrolled proliferation of bone it should not be hard to imagine that that person could potentially get an osteosircoma from that this is why on in-bim exams you shouldn't give terryparatite for more than two years if you give it for more than two years I wish you all the best sounds like you want to give that patient osteosircoma now one other unusual thing you may see on an exam as a risk factor for osteosircoma is if a person has had like radiation to an extremity right having radiation to an extremity is actually a risk factor for the development of osteosircoma of the bone that constitutes that extremity and one thing they may like to do because this one of these things right I get it from students all the time you will be like oh divine they don't they didn't test the classic risk factor I'm used to know the thing is on these exams you also have to apply some wisdom right the thing is if for example they give you a question about a person that has had radiation therapy to the bone right if had radiation therapy to an extremity for some lesion in the past and then they tell you that oh this person took terryparatite for like two weeks like a few years ago and in DC which of the following represents the biggest risk factor for and the less the

the person has osteosircoma in the question which of the following represents the biggest risk factor for the development of osteosircoma in this patient obviously the answer is not going to be terryparatite even if terryparatite is a risk factor the person was exposed to terryparatite for only two weeks so there is no way that can be the thing that's causing the patients of osteosircoma so just one of those weird things you want to keep in mind right so it may give you multiple risk factors but ask yourself which one has the patient been exposed to the most that will likely be the biggest risk factor for that condition with that patient and osteosircomas whenever you're working on osteosircomas this is going to lead into another question that the mb may loves to test you always have to do some kind of chest CT you know why because the most common location of metastasis of osteosircomas is actually the lungs that's also the most common sight of metastasis of choreocardcinomas choreocardcinomas they love to go to the lungs again one of those weird bizarre things you want to keep at the back of your mind on exams so whenever you're working on a osteosircoma you always always need to do a CT chest because you want to rule out meds meds to the lungs and again don't forget your classic image in findings of osteosircoma right called menstrual sombers pattern right basically the sombers pattern you see is just the tumor the malignancy essentially sneaking its way into the periostium going past the periostium that's what you see as the sombers pattern around the presence bone and in generally for pressing has osteosircoma you know you can do bone scans to try to figure out again the extent of the lesion the extent of the metastasis but one classic treatment for osteosircomas that people fall into as a problem on the exams is amputation you almost never amputate the extremity

of a pressing that has an osteosircoma typically what you do is you would reset the lesion from within the bone it's almost like you're scooping out the lesion right but you always almost always try to salvage the limbs it's just one of those weird things they may say no I don't need to know that for an exam and then you sit on an exam and then you start scratching your head I don't want you scratching your head on an exam right so it's just one of these big things I think you should keep at the back of your mind you always try limb salvage therapy you're gonna get out the lesion but you don't need to amputate the person's extremity while you're at it and then what if they give you a question about a child and they tell you that this child for the last few weeks this child has been having very high fever has a lot of swelling around his left femur has a lot of erythema around his left femur and they may even give you some labs they may tell you that this child has a hemoglobin of seven so this child is anemic the white count is really high this is like 17,000 ESR CRPL DH all elevated you're like man does this child have an infection well you notice that man this child has been having this thing for weeks if you see stuff like this you absolutely absolutely want to think about an Ewings sarcoma you want to think about an Ewings sarcoma and Ewings sarcoma so one thing your friends at the M&M love to do is they will tell you that the biopsy delusion and the so small round blue cells if you see stuff like that again you want to think about Ewings sarcoma and don't forget this is one of those things that you treat with actinomycind or sometimes we call that actinomycin on an MBM exam and it also has one of those fancy genetic translocations right it has the 11-22 translocation so you create like this fusion protein called like EWS FLI right and when you do image of the bon

e typically you're like a plane radiograph you're very likely going to see this moth eating pattern is almost like some parasite has just been leaching leaching leaching leaching of the bone right for a long time right so if you see a young kid having a bone malignancy and they have like almost like an infectious presentation high fevers severe joint pain swelling high white count low hemoglobin elevated ESR CRPL DH you absolutely want to think about an Ewings sarcoma under those circumstances and these people again they can have that onion skin pattern of the periostiom on imaging that's something you want to commit to memory for exams and one thing your friends at the MBM love to go after is they can give you a malignancy and ask oh what is the worst predictor of prognosis in this patient it's actually the presence of metz so when a person has metz in Ewings sarcoma that usually portends like something really bad right the the person has like an awful awful awful awful prognosis if they don't have distant metz the prognosis is not too bad but if they have distant metz it is not good at all I'll tell you that right now now one of the thing you want to keep in mind what if they give you a question about like a 70-year-old female and they tell you that she has been having like severe pain around her left wrist and they tell you that oh she has actually had like two fractures of that wrist over the last three years and then they give you some labs you notice that a creatinine is like 3.5 and they tell you that you know she's also been in an out of the hospital or she has required a lot of anti-biotics in recent times for all these infection infection infection if you see this what should you be thinking about I really hope you're telling me that this person has multiple myloma right I really hope you're thinking of multiple myloma remember multiple myloma on animbime ex

am will present with crap symptoms right so those what does the crap stand for right like C-R-A-B right so the C stands for hypercalcemia right and what's the mechanism there remember those multiple myloma is a tumor of plasma cells so those plasma cells they can produce interlooking one another name for interlooking one is osteoclast activated in factor that interlooking one can basically go and essentially leach away bone I mean literally another name for it osteoclast activated in factor is going to activate osteoclast and that's going to leach away the presence bone right and that's going to cause hypercalcemia right and then the R stands for renal failure right because again remember in multiple myloma those people can begin to develop amyloid in the kidneys right from those light chains so that amyloid can damage the presence kidneys right and then the anemia why do these people get the anemia well those plasma cells they take over the entire bone marrow so you have like ineffective hematopoietes you know they'll be able to make great blood cells and again if you're leach and away bone you're gonna have bone pain so that's the crap hypercalcemia renal failure anemia and bone pain and the thing is if a person is less than 40 years old on an endemic exam please don't pick the answer that says multiple myloma is almost like we give you a question about a female in her 60s and I'm like oh she has MS no people in their 60s can they get MS in the real world absolutely but on endemic exams no that's not a thing right usually the people that get MS on endemic exams almost like 98% of the time are females in their 30s females in their 30s that's like the classic demographic for MS multiple myloma is gonna be an old person on an endemic exam it's never going to be a person let me not say never but you'd be hard pressed let me put that term you'd be hard pressed to find an

endemic question where pressing has multiple my loma and they're less than 40 years old even in the real world almost 90% plus of people that have multiple myloma at over the age of 40 right and again don't forget your crop your crop symptoms right so what are you gonna do in terms of what or what's the classic finding on imaging for a person that has multiple myloma again don't forget you'll find these punch-tout lidic lesions and they're usually like pretty well circumscribed right well demarcated multiple punch-tout lidic lesions that's the classic thing and obviously if you want to make the diagnosis right you're gonna perform like an S-PEP or U-PEP right so a serum protein electrophoresis or urine protein electrophoresis and the thing is multiple myloma they may try to trick you into doing surgery or whatever or don't do any of those things but most of my multiple myloma naming exams you try to with chemotherapy right and the chemotherapy sometimes believe it or not can be there's this drug known as bortezomib bortezomib is a pretty useful inhibitor right that can be used in the treatment of multiple myloma also some therapies for multiple myloma include drugs like phallidomide right you may be like divine phallidomide are you kidding well well the people that are getting multiple myloma these are people that have no more reproductive potential right so they're not gonna be having kids that have for chomilia anytime soon right and then typically they can ask you a question and say which of the following interventions can be used to decrease the risk of pathologic fracture in the patient you want to think about this phosphonids right this phosphonids whenever a person has a malignancy and it involves the bone this phosphonids are usually very good adjuncts to treatment so that they don't run into they don't run into trouble and then as I wrap up this podcast righ

t so you want to know some things about match to bone right so remember most the most common malignancies that can cause bone met's right it's gonna be either prostate cancer in men or breast cancer in women right and despite what you see many resources most bone metastasis tend to be osteolidic most bone met's tend to be lyric the only ones that tend to be plastic like prostate cancer prostate cancer is always gonna be plastic on an in-bim exam and breast cancer in some cases can be plastic but usually the most common kind of bone lesion associated with breast cancer believe it or not is a lyric is a lyric bone lesion when a person has bone met's or you suspect bone met's the person's outfoss can be elevated this is why seen an outfoss elevation on an in-bim exam does not always be in lever pathology the only way that you can say oh outfoss on an in-bim exam means that the person has like a billiard pathology is if in addition to the outfoss being they have an elevation in ggt right or they have an elevation in something called the 5 prime nucleotides those are things that tell you oh okay this person likely has bone met's on on the exam and again if you want to evaluate the extent of presence bone met's or use a spiger presence bone met's you want to go ahead and build bone scan right this is something that's commonly done in radiology get a bone scan and you just see like hot spots everywhere especially if it's a plastic lesion right definitely read a ton of those studies for people that have a history of a prostate cancer right and then don't forget bisfoss for needs at the drugs you want to use again to decrease the risk of the person having like pathological of the person having pathological fractures the thing is for pressing has a lot of lesions in their spine you can actually take them to like orthopedic surgery or like neuro spine surgery and then they will

basically please like rods to stabilize those bones so that those things don't fracture and you know ultimately give rise to some kind of a paraplegia now one high-yield thing I want to see to conclude the podcast is whenever a person is having orthopedic surgeon an embankment exam is there something you're supposed to do before the surgery starts I'll really hope you're saying yes divine we want to give those people sephazolin right remember if you've done the insurgere rotation I feel like surgeons they love ants have ants have ants have ants have right ants have is like probably part of the surgery also a bit at this point right you're supposed to give that sephazolin about 30 to 60 minutes before the surgery starts right and obviously for pressing has like analogy to like a penicillin of some sort like I'm pursuing or whatever you shouldn't give sephazolin right remember sephazolins is a first generation sephalosporin right so again whenever a person is having orthopedic surgery you always need to give some kind of pre-op antibody prophylaxis with with sephazolin that's the drug you want to give right and you basically give like an IV formulation pretty much for the most part of the pressing should be fine that actually decreases the risk that the person will develop infection so let's go ahead and pause here for today if you're interested again like I announced this morning I have a step 2 ck course coming up on the 6th and the 7th of November from 11 a.m.

mountain standard time to 4 p.m. mountain standard time so be five hours over two days you'll be the 6th and 7th of November if you're interested just shoot me an email and I'll be happy to give you some more information basically we're going to over 10 hours cover like 700 800 concepts and like internal medicine, PEAT surgery, OB-GYN, psychneural right obviously we're going to spend a lot of the time probably like almost half the time on I am and neuro and surgery mostly I am for the most part right but again we're going to cover all those subjects cover all these fracture patterns just a lot of things that the mbme cares about especially with the amorous in exams we'll go over those during the course and then the mbme testicum strategies class that's going to be taking place on the 5th of November is going to be taking place from 2 to 4 30 p.m.

mountain standard time basically mountain standard time is two hours behind Eastern time and again I'll have a bunch of mbme style questions that I'm going to use I mean I've I teach I've thought testicum strategies for four years right so I'm pretty good at writing mbme questions so I have a bunch of mbme style questions that I wrote that again reflect more not questions from like back in the day but like the more recent questions right that look a lot like the questions from the new 3120 right so we use those questions and I use a very systematic approach over a two and a half hour period to go over principles behind testicum that should be very helpful for anyone taking step 2ck or taking step 3 and you know please subscribe to the website remember the divine intervention podcast.com and then we also have these podcasts on Apple podcasts on Spotify on on Google Play so please subscribe and then you can also subscribe to the You Tube channel is called Divine Intervention US Mini Podcasts and Videos now one thing I want to share I guess actually two things I want to share in terms of life lessons so the first one just concerns the nrmp process so we know that today was the deadline right where people it not necessarily the deadline but this is the day where you want to turn your ear to your application whether you have a you don't have a score that has come in or rec letters and coming doesn't matter you always want to submit on the first day that's always the smart prudent thing to do right so the thing with that is again people become super anxious like am I going to get interviews I'm not going to get this I'm not going to get that just become be patient right um don't freak out because again I know that this is like a very I mean I've have interacted especially with my role reviewing applications preparing people for like doing mock interviews with folks and stuff

I've seen the just heightened level of anxiety that's prevalent amongst mixed students with this time of the year just calm down right again if you have like a decent application chances are you'll get a decent number of interviews if you know you don't have the strongest scores known to man or you're not very competitive for a discipline you want to apply broadly right want to apply to as many programs as you can and if you have connections of programs if you have people that can make calls for you go ahead and have those people make those calls right and some cases especially if it's a program that you have like some strong ties to but you know you're not as competitive for that program you can send a letter of interest again notice I said if you have like letters of intent that things you should probably send a little later in the process but there's exceptions to that rule right if there's a program that you have very strong ties with or you have connections with you can reach out to them even before they start sending out interview invites so just one of those things you want to keep in mind and obviously want to do some mock interview practice right if you're interested in mock interview practice I do mock interviews again I've been on an admissions committee of a top three medical school and I'm very familiar with the residency selection process for many disciplines so if you want practice with more in interviews again just shoot me an email through the contact button on the website and I'd be happy to guide you in the right direction and then one other thing I would say with this whole much process is again with this cycle with this zoom cycle that we essentially have it makes sense to apply to a decent number of programs right even if you're a high score right because normally let's say you're applying to some specialties where oh with my score I just need to

apply to 20 programs this year apply to more than 20 programs because again there is very limited consequence to this cycle you don't have to travel anywhere you don't have to rent hotels or Airbnb's you don't have to go for any applicant dinners nothing so even the high scores will be applying to a ton of programs this year right so that I just don't have time to explain my reasoning behind that but basically you don't want to put yourself in a tough situation or not get enough interviews or be shocked at where you end up ranking because you did not go on enough interviews because you did not apply to enough programs in the first place right so you want to be somewhat liberal in your size I'm not saying oh if normally you should apply to 20 you apply to 100 no that's not what I'm saying if you apply to 20 maybe apply to 35 or 40 this year right just like a prudent thing to do obviously cases vary by individual let's say you have like 270s on both your USML exams you have like a ton of research ton of everything you probably still get by with applying to like 20 programs as you mean you know you have like a good personality good demeanor and stuff like that so that's just something you want to keep in mind keep in mind and then the life lesson I want to share today it's actually based on so you know many of you that listen to this podcast you know my Christian there's a message I listened to by my pastor that was actually yesterday and this statement really stuck out to me and I figured I'd just share with you guys and also just explain how it relates to our life's medical professionals and the statement was that things that are that like things that have treasures behind them always have restricted entry right I'll say that again things that have treasures behind them always have restricted entry so one thing I would say is if you want something good in life if you

want great things in life you need to be willing to work hard for it when you see people do so well on USML exams and you marvel at the wonderful things they just did or you see people they're getting interviews left right and center is not because they have any kind of special ability those people just worked hard right they were willing to put in work that many people were not necessarily willing to put in and I know some of you may be like but divine I worked hard but I still did not get the kind of scores I wanted um the thing is the facts that your work hard does not mean you're gonna succeed it's one thing to work hard but it's another thing to work hard in the right to work right that's one thing that many met students kind of fall into and that's I'll say probably like one of the things that brings people to me as you know they come to work with me as a tutor is that you see people you're doing all these things they're spending ten hours a day studying but for their particular disposition as individuals the way they're studying is no one will ultimately bring them success or the way they analyze questions or the way they take tests is no one will ultimately lead them to success so that's something you need to be careful about don't just throw all your energies into something make sure it's something that will ultimately work well for your predisposition right so like for example like myself I'm not I'm not a Anki is just not the way I study it just doesn't work for me that way I study in very different ways I mean that's one of the reasons why you see me make a lot of podcasts and videos I'm more of an audio visual learner I'm not a notaker I really really really hate taking notes right I mean I have really good handwriting but I really hate taking notes so you you the thing is before you work hard ask yourself am I doing the right work right work hard in the

right work and you get success but going back to my original point if you want something good in life right if you want to match into Durham or if you want to do this or that again you can't because believe it or not I have actually met met students that are just straight up lazy right straight up lazy again I know you may think that oh everyone that is a medicine is hard working that's not true I'm telling there's the reason why some people feel exempt is just because they're just lazy they are not willing to put in the work they're not willing to be throwing their prep they just want to get by right but the thing is that get by spirit would obviously if you get by like there are many if you get by you will get opportunities that most people get right but if you want to be the elite of the elite if you want to do really well if you want to get those opportunities that not everyone gets you need to work by means of restricted entry what do I mean by restricted entry means you need to make sacrifices again there's nothing good that comes in life without you making sacrifices right things that are genuinely good you need to make sacrifices for those things right I mean like there's even this part of the bible that says that you should enter by the narrow gates right because narrow is the way that leads to life and there are few that take it right but broad is the way that leads to darkness and there are many that take that route right so the thing is brought something that is brought right doesn't really you can easily walk through that thing without any restrictions right but you know if you want to like for example the Lakers right they won the championship and again in case you've not noticed I'm a LeBron fan at this point the Lakers they won that championship because they went through an adverse process they did many things that people are not willing to do right Le

Bron has a great body because he does many things that people are not willing to do so what are those goals you have in your life that you're like man I really want to accomplish this thing I want to be the head in this particular area of life make those sacrifices right there's no glory without a story behind it whenever I see a message and it says oh I got it 270 and I just studied for a week and did this and did that they're pretty much lying to you they're just trying to project this false sense of humility initially those people have worked really hard for a long enough period of time to get those kinds of results right so again there is no glory without a story behind it so just be mindful of that so thank you for listening I will see you in the next podcast God bless you and have a wonderful evening thank you

OCD is unilateral; growing pains are bilateral.

Small bones (hand/foot) with stippled, popcorn-like calcifications.

Cartilage (hence "osteo-" and "-chondro").

The lungs (requires CT chest).

CRAB criteria (C=Hypercalcemia, R=Renal failure, A=Anemia, B=Bone pain).

t(11;22), creating the EWS-FLI fusion protein.

History of retinoblastoma, Paget's disease, and prolonged use (> 2 years) of teriparatide.

"Bull's eye" pattern—a radiolucent center surrounded by dense, sclerotic bone.

Plasma cells produce cytokines (like IL-6) that activate osteoclasts, leading to excessive bone resorption.

Osteochondroma.

Low grade are highly treatable; high grade can progress to chondrosarcoma (loss of well-defined margins).

Ewing sarcoma.

History of retinoblastoma, Paget's disease, and prolonged use (> 2 years) of teriparatide.

"Bull's eye" pattern—a radiolucent center surrounded by dense, sclerotic bone.

Plasma cells produce cytokines (like IL-6) that activate osteoclasts, leading to excessive bone resorption.

Osteochondroma.

Low grade are highly treatable; high grade can progress to chondrosarcoma (loss of well-defined margins).

Ewing sarcoma.