Crack the Core Exam Vol 1 PDF

ADH_2020  CRACK THE CORE EXAM 7th (2020) EDITION VOLUME 1 WRITTEN & ILLUSTRATED BY: PROMETHEUS LIONHART, M.D. ADH_2020  CRACK THE COKE EXAM -VOL 1 SEVENTH ED. - VERSION 1.0...

ADH_2020  CRACK THE CORE EXAM 7th (2020) EDITION VOLUME 1 WRITTEN & ILLUSTRATED BY: PROMETHEUS LIONHART, M.D. ADH_2020  CRACK THE COKE EXAM -VOL 1 SEVENTH ED. - VERSION 1.0 DISCLAIMER: READERS ARE ADVISED - THIS BOOK IS NOT TO BE USED FOR CLINICAL DECISION MAKING. HUMAN ERROR DOES OCCUR AND IT IS YOUR RESPONSIBlLITY TO DOUBLE CHECK ALL FACTS PROVIDED. TO THE FULLEST EXTENT OF THE LAW, THE AUTHOR ASSUMES NO RESPONSIBILITY FOR ANY INJURY AND/OR DAMAGE TO PERSONS OR PROPERTY ARISING OUT OF OR RELATED TO ANY USE OF THE MATERIAL CONTAINED IN THIS BOOK. ISBN: 9781673734270 INDEPENDENTLY PUBLISHED — PROMETHEUS LIONHART (EARTH DIMENSION C-137) COPYRIGHT © 2019 BY PROMETHEUS LIONHART ALL RIGHTS RESERVED - UNDER INTERNATIONAL AND PAN-AMERICAN COPYRIGHT CONVENTIONS. THIS BOOK, OR PARTS THEREOF, MAY NOT BE REPRODUCED IN ANY FORM WITHOUT PERMISSION FROM THE AUTHOR. COVER DESIGN, TEXTS, AND ILLUSTRATIONS: COPYRIGHT © 2019 BY PROMETHEUS LIONHART ADDITIONAL ART PROVIDED BY: HAAJAR DESIGN/SHUTTERSTOCK.COM NO SLAVE LABOR (RESIDENT OR FELLOW) WAS USED IN THE CREATION OF THIS TEXT 2 ADH_2020  VOLUME 1 WRITTEN & ILLUSTRATED BY PROMETHEUS LIONHART, M.D. 01 - ART OF WAR ------9-33 06 - ENDOCRINE ------343-361 02 - PEDIATRICS ------35-139 07 -THORACIC ------363-430 03 - GASTROINTESTINAL ------141-222 08 - CARDIAC ------433-466 04 - URINARY ------225-269 09 - NUKES ------469-544 05 - REPRODUCTIVE ------271-341 VOLUME 2: TOPICS: NEURO, MSK, VASCULAR, IR, MAMMO, STRATEGY WAR MACHINE: TOPICS: PHYSICS, NON INTERPRETIVE SKILLS, BIOSTATS 3 ADH_2020  LEGAL STUFF READERS ARE ADVISED - THIS BOOK IS NOT TO BE USED FOR CLINICAL DECISION MAKING. HUMAN ERROR DOES OCCUR, AND IT IS YOUR RESPONSIBILITY TO DOUBLE CHECK ALL FACTS PROVIDED. TO THE FULLEST EXTENT OF THE LAW, THE AUTHOR ASSUMES NO RESPONSIBILITY FOR ANY INJURY AND/OR DAMAGE TO PERSONS OR PROPERTY ARISING OUT OF OR RELATED TO ANY USE OF THE MATERIAL CONTAINED IN THIS BOOK. ARE RECALLS IN THIS BOOK? ABSoLUTELY NOT THE AUTHOR HAS MADE A CONSIDERABLE EFFORT (IT'S THE OUTRIGHT PURPOSE OF THE TEXT), TO SPECULATE HOW QUESTIONS MIGHT BE ASKED. A PHD IN BIOCHEMISTRY CAN FAIL A MED SCHOOL BIOCHEMISTRY TEST OR BIOCHEM SECTION ON THE USMLE, IN SPITE OF CLEARLY KNOWING MORE BIOCHEM THAN A MEDICAL STUDENT. THIS IS BECAUSE THEY ARE NOT USED TO MEDICINE STYLE QUESTIONS. THE AIM OF THIS TEXT IS TO EXPLORE THE LIKELY STYLE OF BOARD QUESTIONS AND INCLUDE MATERIAL LIKELY TO BE COVERED, INFORMED BY THE ABR'S STUDY GUIDE. THROUGHOUT THE TEXT THE AUTHOR WILL ATTEMPT TO FATHOM THE MANNER OF QUESTIONING AND INCLUDE THE CORRESPONDING HIGH YIELD MATERIAL. A CORRECT ESTIMATION WILL BE WHOLLY COINCIDENTAL. HUMOR/ PROFANITY WARNING I USE PROFANITY IN THIS BOOK. I MAKE "GROWN UP" JOKES. PROBABLY NOT A GOOD IDEA TO READ THE BOOK OUT LOUD TO SMALL CHILDREN OR ELDERLY MEMBERS OF YOUR CHURCH / TEMPLE / MOSQUE. NOW IS NOT THE OPTIMAL TIME TO BE RECREATIONALLY OUTRAGED - I'M JUST TRYING TO MAKE THE BOOK READABLE AND FUN. I ALSO TALK A MESS OF SHIT ABOUT DIFFERENT MEDICAL SPECIALTIES. I DO THIS BECAUSE RADIOLOGISTS ARE TRIBAL, AND STROKING THAT URGE TENDS TO CALM PEOPLE. PROBABLY NOT A GOOD IDEA TO READ THE BOOK OUT LOUD TO MEMBERS OF YOUR FAMILY THAT ARE IN SPECIALTIES OTHER THAN RADIOLOGY. THE TRUTH IS I RESPECT ALL THE OTHER SUB­ SPECIALTIES OF MEDICINE (EVEN FAMILY MEDICINE) - THOSE ARE DIRTY JOBS (POOP, PUS, &. NOTE WRITING) BUT SOMEONE NEEDS TO DO THEM. IF YOU STILL FEEL THE DESIRE TO EMAIL ME ABOUT HOW I HURT YOUR FEELINGS AND RUINED YOUR LIFE, CONSIDER THAT "MAYBE PEOPLE THAT CREATE THINGS AREN'T CONCERNED WITH YOUR DELICATE SENSIBILITIES." 4 ADH_2020  WHAT MAKES THIS BOOK VNIQUE? SHORT ANSWER — FUCKING EVERYTHING HOW? — WELL FOR STARTERS, THESE BOOKS WEREN'T WRITTEN BY 30 RESIDENTS, 20 FELLOWS, AND 10 TURBO NERD ATTENDINGS. INSTEAD THE BOOKS WERE WRITTEN BY A RELENTLESSLY SELF IMPROVING MANIAC, DRIVEN TO PURGE THE HERETICS (ORC SCUM), LAUNCH VENGEANCE UPON THIS PLANET, AND DELIVER MERCILESS JUSTICE UPON THE ENEMIES OF FREEDOM AND LIBERTY THE IMPETUS FOR THIS BOOK WAS NOT TO WRITE A REFERENCE TEXT OK STANDARD REVIEW BOOK, BUT INSTEAD, A STRATEGY MANUAL FOR SOLVING MULTIPLE CHOICE QUESTIONS FOR RADIOLOGY THE AUTHOR WISHES TO CONVEY THAT THE MULTIPLE CHOICE TEST IS DIFFERENT THAN ORAL BOARDS IN THAT YOU CAN'T ASK THE SAME KINDS OF OPEN-ENDED ESSAY-TYPE QUESTIONS. "WHAT'S YOUR DIFFERENTIAL?" QUESTIONING THE CONTENTS OF ONE'S DIFFERENTIAL WAS THE ONLY REAL QUESTION ON ORAL BOARDS. NOW THAT SIMPLE QUESTION BECOMES NEARLY IMPOSSIBLE TO FORMAT INTO A MULTIPLE CHOICE TEST. INSTEAD, THE FOCUS FOR TRAINING FOR SUCH A TEST SHOULD BE ON THINGS THAT CAN BE ASKED. FOR EXAMPLE, ANATOMY FACTS - WHAT IS IT?... OR... TRIVIA FACTS - WHAT IS THE MOST COMMON LOCATION, OR AGE, OR ASSOCIATION, OR SYNDROME?... OR... WHAT'S THE NEXT STEP IN MANAGEMENT? THINK BACK TO MEDICAL SCHOOL USMLE STYLE, THAT IS WHAT YOU ARE DEALING WITH ONCE AGAIN. IN THIS BOOK, THE AUTHOR TRIED TO COVER ALL THE MATERIAL THAT COULD BE ASKED (REASONABLY), AND THEN APPROXIMATE HOW QUESTIONS MIGHT BE ASKED ABOUT THE VARIOUS TOPICS. THROUGHOUT THE BOOK, THE AUTHOR WILL INTIMATE, "THIS COULD BE ASKED LIKE THIS," AND "THIS FACT LENDS ITSELF WELL TO A QUESTION." INCLUDED IN THE SECOND VOLUME OF THE SET IS A STRATEGY CHAPTER FOCUSING ON HIGH YIELD "BUZZWOKDS" THAT LEND WELL TO CERTAIN QUESTIONS. THIS IS NOT A REFERENCE BOOK. THIS BOOK IS NOT DESIGNED FOR PATIENT CARE. THIS BOOK IS DESIGNED FOR STUDYING SPECIFICALLY FOR MULTIPLE CHOICE TESTS, CASE CONFERENCE, AND VIEW-BOX PIMPING/QUIZING. 5 ADH_2020  Radiology Master of Sport - National Champion Americans love to fight. Americans love the champion. This right here is about recognizing a commitment to being the best. Being the best, standing on the top stand - and more importantly the quest to stand on the top stand and wear the yellow medal is what I want to recognize. The quest is very lonely. They say it is lonely at the top - that is not true. When I started to become recognized internationally as the top educator in the field I suddenly had alot of people who wanted to be my friend. I didn’t have any friends on the way there - nobody was getting up at 4 am with me to write... nobody, not one person. It was just me - alone. It is lonely getting to the top and that is where most people fall off. It's Friday and everyone else is going out, or there is a party or whatever - I’m tired and I want to sleep in. I was on call last night - it is just not worth it. What I’m hoping to share is that for me that is not what life is. Life is about being the best person you can be in whatever it is you arc doing. That does not have to be Radiology, but because you arc reading this book well that is what it means for you now. You make the quest. If you get the top score on the exam - I'll be putting your name in this book next year and you can motivate the next legend of tomorrow. Plus, I’ll give you some money and have an enormous lion trophy made for you. The most important thing is not actually winning. People think I only care about winning because I rant and rave about how only the gold medals count - but the quest is what I really value. I'm not training for silver. I'm training for gold. The quest for gold is more important than someone handing you a gold medal. The katana sword of the black dragon society cannot be stolen - it can only be earned. Outcomes really don’t matter, because the truth is in this life you can do everything 100% perfect and still fail and you can do almost everything wrong and still win. If you don’t focus on outcomes and instead the quest itself you will get something much greater besides a high probability of passing the test - what you can gain from the quest, the ability to really dedicate yourself to something 100% - it is a skill you can use for the rest of your life. This is the way to always achieve victory. Once you know the way, you can see it in all things - as the samurai say. HALL OF CHAMPIONS 6 ADH_2020  I FIGHT FOR THE USERS -TRON 1982 7 ADH_2020  8 ADH_2020  1 THE ART OF WAR PROMETHEUS EIONHART, M.D. The art of war is of vital importance... It is a matter of life and death, a road either to safety or to ruin. Hence it is a subject of inquiry which can on no account be neglected. - Sun Tzu My idea for this first chapter is to provide some guidance on how to “wage war.” I’m going to share with you my philosophy on training and performing optimally under pressure. Specifically, I want to give you some ideas on how to deal with test anxiety, fear of failure, motivation, and self mastery. June / November is Coming 9 ADH_2020  SECTION 1: Detail Assessment and Planning Before we get started with the “when” and “how” of the exam you need to have a clear understanding of the “what. ” Let us begin with the most important topic - “passing. ” The official stance is that everyone can theoretically pass the examination - which sounds good if you are simply testing for safety and competence. The problem occurs when you bring in professional statisticians and test metric experts (which all professional exams do). These people insist on creating a normalized curve to validate the exam. An examination with 100% pass rate is statistically invalid (it wasn’t sensitive enough to detect the “dangerous radiology trainees”). If they passed everyone they would totally invalidate their own exam. They would risk public perception perceiving the exam as a cash grab disguised as a formality. If they failed more than 20 or 25% they would have a full revolt to deal with (lead by Program Directors who want you reading nodule followups not studying for a repeat exam) - let us not forget the entire reason the US boards were restructured was to eliminate off service study time for the more senior residents (oh sorry, I meant “trainee” or maybe “learner”). They can’t set a hard number or they risk one of these two scenarios. So, like every other standardized exam you’ve ever taken, it’s curved. They may not “curve” the exam in the traditional sense, but questions will be removed until the statistics provide an acceptable yield of passing and failing scores. This is standard operating procedure on any exam of this magnitude. Which leads me to my second point. Frequently I am asked “what do I need to score to pass? ” Or “how many can I miss ? ” You can’t think about this exam as requiring a certain raw score (even though they will give you one - constructed via space magic). You can’t say I got 9/10 correct so I passed. What if everyone else got 10/10 right? You just got the lowest score in the country. If anyone is gonna fail it is you - despite getting 90% of the questions right. You need to think about it as your score relative to the rest of the room. Historically around 10% of people fail, and 1-2% of people condition physics. So, if you score in the 15th percentile or higher you are probably safe.... probably. Another common question is, “how many subjects can I condition?” On the old oral boards there was a certain number of subjects that you could condition (fail) without having to retake the entire exam. You would just have to come back in a few weeks and be tested on that subject (or subjects) to meet criteria for a pass. The original official statement on the CORE exam was something similar, that you could fail up to five categories. However, when no one ever conditioned anything other than physics after 5-6 years people started to notice that was probably bullshit. Now there has been an official statement that only physics can be conditioned. Your clinical totals are lumped into a raw score and then compared to a “predetermined” minimal score (that is later adjusted to fail around 10% of people). 10 ADH_2020 You may be thinking to yourself “That doesn't sound hard. I’ve never scored that low on anything.” There is no greater danger than underestimating your opponent. You have never competed at this level before. Your shelf exam scores , USMLE, etc... don’t mean shit because you were competing against Family Medicine , Peds, Psych, etc.... This time you are competing against Radiology Residents only. Yes, it is less competitive compared to the “glory days” but Radiology still has a lot of smart people in it. Smart enough to realize how to avoid the worst parts of medicine anyway. Plus, you are dealing with an extremely motivated group. Most reasonable people are terrified to fail this exam and will therefore be putting considerable effort into passing. But Prometheus!? I heard someone say “all you need to do is take call to pass. ” Yes... someone did famously say that. Everyone has an agenda in this life. My agenda is to help you pass this exam. Other people... perhaps they want you to take call for them. Or perhaps they just want to make sure you are “safe” and “protect the public.” Those people (if they are reading) can prove their virtuous motives by writing questions that are fair, clinically relevant, and follow topics on the official provided study guide. If your motivations are truly genuine consider writing a fair test, free of trickery, on bread and butter topics - as this would make board review books unnecessary. I prefer teaching clinical radiology anyway (RadiologyRonin.com) Let us switch gears and discuss the structure of the exam. The exam is a multiple choice test consisting of around 600 questions. The punishment is administered over two days, the first is typically longer than the second (7.5 hours and 6 hours respectively). They give you 30 mins “break time” but that is built into the exam. You can take this 30 mins in any interval or ratio you want - (example — you could take thirty 1 min breaks, six 5 min breaks, etc...). The CORE Exam covers 18 categories (sometimes 17 - in Chicago). The categories include: breast, cardiac, gastrointestinal, interventional, musculoskeletal, neuro, nuclear, pediatric, reproductive/endocrinology, thoracic, genitourinary, vascular, computed tomography, magnetic resonance, radiography/fluoroscopy, ultrasound, physics, and safety. This book is outlined to cover the above sections, with the modalities of CT, MRI, Radiography, Fluoroscopy, and Ultrasound integrated into the system based chapters as one would reasonably expect. On the exam, Physics questions are integrated into each category with no distinct physics examination administered. However, the physics section is still considered a virtual section, and you can fail / condition it. In fact, the physics portion is actually the overall largest section. My book “The War Machine” is dedicated to review of physics and the various non-interpretive skills. Useless trivia from a portion of the Radioisotope Safety Exam (RISE), one of the requirements for Authorized User Eligibility Status, is also included within the Exam - and this material is also distributed appropriately in my various texts. 11 ADH_2020  SECTION 2: Waging War In the previous section, I tried to introduce the idea that the exam should not be viewed as a test on which a certain “minimum score” is required to pass. Instead, I want you to look at the exam as a contest in which you must finish in the top 85% to achieve victory. I’m not trying to scare you. I’m just trying to help you understand that you must take this exam serious. It’s tough and smart people fail it every year. Over the next 6-12 months, when you are out partying and horsing around - remember that someone else out there at the same time is working hard. Someone is learning, getting smarter, and preparing to win. Life is a struggle. Everybody fights - and that doesn’t mean getting punched in the face. That means not hitting the snooze button, managing your personal relationships, dealing with disability, trying to do the right thing for your children - etc... etc... and everyone gets asked the same question - “Can I move on, or am I going to give up on my dreams?” Transform a threat into a challenge. A life free of struggle is a life void of meaning. We are bom for battle. Battle against the beasts of the jungle. Battle against the rival tribes. And... yes... battle against each other on the glorious field of multiple choice questions. I encourage you to embrace this as a great opportunity to weaponize your will. The time has come my brothers (and sisters) to show no mercy. Retribution is at hand. Let fury guide you and let vengeance be your song. Thank all the Gods of War for providing you with this opportunity to prove your greatness. 12 ADH_2020  SECTION 3: Attack By Stratagem “Victorious warriors win first and then go to war ” As we begin our discussion of specifics, I will now share with you my 3 Promethean Laws for success on this exam and in life. These laws are the beginning of understanding “the way,” and once you know “the way” you will begin in see it in all things. LAW 1 - You must do anything your opponents are willing to do. Example: If everyone is reading a certain book, then you must also. If everyone is using a particular q-bank (or banks) then you must also. If everyone is studying a certain amount per day then you must also. LAW 2 - You must do things your opponent is NOT willing to do. Terry Brands once told me the secret to being a world champion is actually very simple - all it takes is doing something no one else is doing - and then do it every day. It doesn’t even matter what it is, as long as no one else is doing it. This principal has more to do with developing a mental edge than cultivating a specific skill set. Example - Setting your alarm at 2 am to study while everyone else is asleep. Listening to lectures while driving to work, while in the shower, while pooping. Example - Finding ways to maximize your study time. Specific ideas (things that I do) include the application of “conscious labor’’ to improve efficacy in specific tasks. Example -1 never take a shower for longer than 3 mins. I turn the water on and get in (while it’s freezing cold) - I play the game of enduring the cold shower as it heats up. This may sound crazy but it is a method for callusing the mind. It helps me remember my priorities. I want to win more than I want to enjoy a warm shower. Warm showers don’t help me win. Less extreme examples would be never touching the snooze button. Not watching any tv, movies, news, comics, etc... until victory is achieved. This is not punishment - and should not looked at as such. These are habits of the ultra-successful. People who are competing for Olympic gold medals tend to know dick about anything other than their sport. I remember seeing an interview with a female gold medalist (1 don’t recall the sport) but the reporter ask her who she was supporting in the presidential election and she didn’t even know who was running. She acted embarrassed and people watching that probably thought to themselves “Dumb jock! Doesn’t even know who is running for President!” The people thinking that will never understand what it’s like to achieve an elite level of success at anything. Knowing political trivia doesn’t help her win at gymnastics (or whatever) and time spent on anything other than her craft is wasted. Consider treating your preparation for this exam as if you were in training camp for an Olympic title (or world championship boxing / MMA fight). This mentality is very useful for maintaining your priorities. So remember - while you are wasting time the enemy is training and you can’t allow them to work when you are not (see Law 1). Minimize distractions - Maximize productivity. 13 ADH_2020  LAW 2 - continued... Example - Doing things to improve your mental conditioning. Like a runner might swim to help cross train muscles that are also useful to running. This is where the habits of the “Sly Man” are useful (I’ll tell you more about the “Sly Man” later in the chapter). Improving your focus through forcing yourself to be present in the moment. Not allowing yourself to be distracted by anxiety, fear, or regret. Present in the moment. Looking for ways to improve. Etc... LAW 3 - Performance on “Game Day” must equal performance in practice Let us take a few minutes and discuss “test anxiety. ” “Anxiety” is a dishonest word though isn’t it? Let’s use a more accurate word. FEAR No... I’m not afraid. I’m way too macho to be afraid of things. There is a difference between being afraid, and being a coward. Only crazy people don’t experience fear. It’s ok to be afraid. If you let that fear dominate your decision making... that is when you run into In brightest day, in blackest night, problems. No evil shall escape my sight Let those who worship evil's might, The inability to control fear is the root cause of the Beware my power, Green Lantern's light “test anxiety ” problem. Fear more than anything else Members of the elite Green Lantern Corp keeps people from achieving their full potential in harness the power of "will" to combat the evil forces of "fear” sports, life, business - in everything. Fear of what?? Fear of failure right? Nope... That is Notice that all these feeling of not it. That is not what you are afraid of. It’s not dread of anxiety are focused on failing. It is the fear of a perceived threat to your ego, the future - the consequences your self esteem. The fear of looking bad and getting which occur after you have embarrassed in front of your peers. The fear of being failed. This problematic focus exposed as a fraud. Not really smart enough to be a on the future will become Radiologist. “Imposter Syndrome” important as we proceed with this discussion. Agree? Now... let us talk about how to conquer fear and channel all that psychogenic energy into a powerful motivated force. 14 ADH_2020  SECTION 4: Weaknesses and Strengths "Confronting fear is the destiny of the Jedi.” I want to take a few minutes taking some trouble with words, to help explain the various strategies for controlling fear, and obliterating the negative causatum of anxiety on your game day performance. Controlling fear involves two things: (1) choice, and (2) strategy. The “choice” is the conscious decision to confront your fear. Once you have made the decision to confront it, you can then begin to implement a “strategy”. The strategy that I am going to suggest is to not consider this as an effort to eliminate fear. Fear is normal. Only crazy people don’t have fear. The goal is to increase courage. Mechanism 1: Generating Courage Through Purpose One powerful mechanism to increase courage is to have a goal or purpose that is worthy. For example, a mother may run into a burning building to save her child. Does she do this because she is no longer afraid of fire? Or does she do it because her purpose as a mother out weighs the fear and allows her to generate extreme courage? Purpose → Courage Mechanism 2: The Perspective of the Joker Another mechanism for overcoming fear is to begin to view the world from a certain point of view. A point of view similar to that of the Court Jester. The point of view of the Jester (or Joker) is to view not just the various social institutions, but all formations of the natural world as games. You must be careful of the word “game.” When people use the word “game” they often mean “frivolous.” There can be important games. Imagine that you were playing a game of Super Mario Brothers. What if you believed that if you fell into a cavern or were bit by one of those plant things (or a turtle) that you would actually die ? Do you think this would make you better at the game ? You’d be terrible at it. You wouldn’t be able to relax, you would second guess every movement, and ultimately your performance would be awful. All because you believed this game was real and the dangers within it were real. Games are best played as games. 15 ADH_2020  Mechanism 2: The Perspective of the Joker - continued... Hopefully you can begin to understand the benefits of this strategy. In viewing stressful challenges as games you can remove the effects of fear. This is not the only benefit though. The sincerity that exists in the nature of play - the act of doing things simply for themselves actually improves your performance. Games are best played as games. Mechanism 3: “The Art of Not Giving a Fuck”. In discussing the perspective of the Joker, people will often become upset and insist the consequences of failure are very real. That the fear of failure is justified. Remember that your fear lives in just one place - your head. Confront the fear rationally. Are you afraid of being embarrassed? I can only be embarrassed if the people I think I’ve embarrassed myself in front of have my respect. If I don’t respect you - your opinion means very little to me. As the Lebowski says “that’s just like your opinion man.” Someone worth respecting would understand the difficulty of the task and not judge you poorly for failure. The only people who never fail are the people who don’t try. Remember, the Joker sees the whole world as game playing. That's why, when people take their games seriously - the people who make stern and pious expressions - the Joker can’t help but laugh. It’s hard to not laugh when you see people pretending that what they do is so very serious. As Bill Hicks would say “It’s Just a Ride” I also hear this a lot: “if I fail the test I’ll lose my fellowship.” First of all you don’t need one - the necessity of a fellowship is a lie propagated by the institution that wants you as a slave for an extra year. Even if you really want to do one - you won't lose it. They won’t even know you failed, and passing is not required even to be accredited at hospitals or work as an Attending. Probably some of your Attendings are international grads who haven’t even sat for the CORE exam yet - I know some of mine were. Plus, they don’t give a shit - they just want you as a slave. If they “take” your fellowship away they might have to do your work - and that would defeat the entire purpose of having fellows. There is nothing really on the line other than your ego. Our minds project a backdrop of fear onto our reality. That is the default setting. This idea couples well with John Danaher’s idea of “the parable of the plank.” Where you can walk on a plank that is strung between two tall laters and be crippled by the fear of falling. But you can walk on the same plank laid on the ground and feel no instability at all. It is the same plank. The only thing that changed was your perception of danger. There is no danger. It is just a game. Games are best played as games. 16 ADH_2020  SECTION 5: Variations and Adaptability I have many hobbies. Disco Dance, Ping Pong, Sunbathe. But my primary hobby is trying to be the best version of myself. I am obsessed with maximizing my potential as a human being. Since this is a competition, I thought it might be helpful to share with you some of my ideas on this topic. I’ll start off by saying that I can’t necessarily help you be “the best.” What we are talking about here is being “the best you.” What we are talking about here is “the quest” - the struggle to be the best version of ourselves. I like to imagine that people are bom as various shaped and sized canisters. Not all of these canisters will hold the same amount of liquid. My Dad used to say “all men were NOT created equal.” It’s just a fact that some people are better at certain things than others. Some people have greater potential than others. We can’t all be Tony Stark. The point is to try and be the best version of yourself. The best you. You want to fill that canister all the way up to the brim. Don’t be the half full bottle, that is only half a life. Method 1: Mental Optimization - The Sly Man I’m sure you are wondering... why is he so “sly” ? The Sly Man is the second aspect of the Joker - the deeper aspect. This concept is based on Gurdjieff’s idea of “the Sly Man” - sometimes referred to as “The Forth Way.” The idea is that when you play you are doing things only for the purpose of doing them. For example, when you listen to music you aren’t trying to get to the end of the song, or count the notes, or derive meaning in the lyrics. You are listening to the music only for the purpose of listening. The other thing that happens as you play, or dance, or listen to music is that you become present (mentally) for the process. This in itself is a method to increase focus, and energy in daily life. This is a method for minimizing day-dreaming and absent mindedness. This is the way of the Sly Man. Study only for the purpose of studying. Avoid the mentality of “getting through the material.” Try and read the material the same way you would if you were reading a novel for pleasure. If done correctly you will find your studying endurance and recall ability improve. 17 ADH_2020  Method 2: Mental Optimization - The Self Remembering Exercise: Most people exist in a state of semi-hypnotic "waking sleep.” Studying or performing like this is not ideal. The “Self Remembering Exercise” is a tool to increase your ability to harness this power and increase your focus. People who really dive deep into this stuff will make a big deal about how “self remembering” and “being present” are not the same thing. For the focused goal of maximizing performance on the exam, I will just say that either will serve the same purpose. How this works is that in the morning (or prior to entering the study hall, or exam room) you must spend 5-10 mins being present in the moment. Close you eyes and repeat to yourself “I am here in this place.” Generate the sense of being present in the current moment. Concentrate only on your breathing once you achieve the state of being present. Mediate until nothing can disrupt you, so that you see and feel nothing - except your own energy. —Shidoshi Senzo Tanaka Why waste time doing this? Meditation makes my penis soft! I agree, it’s not alpha and typically I only endorse alpha male (or female) behavior...but this thing really works. Remember how I said that all your feeling of dread of anxiety are focused on the future - the consequences which result after you have failed? If you center your mind on the present, all that shit melts away. It is really just that simple. Anytime you feel anxiety and dread building inside yourself perform the self remembering exercise. Eyes closed - say “I am here in this place,” build a sense of presence in the current moment, focus on your breathing, and then return to the exam / practice room and proceed to kick ass. Repeat as needed. If necessary add the phrase “retribution is at hand” or “only in death does duty end” or my personal favorite “happiness is a delusion of the weak,” after centering yourself in the present moment. Method 3: Mental Optimization - The Accountability Mirror This is a mechanism I learned from David Goggins. Goggins is the fucking man - if you don’t know about him, he’s worth a google. He is a man that understands the power of true fucking will power. The accountability mirror works like this. In the morning you put sticky notes of the things you want to accomplish in that day on the mirror. Not just individual tasks but how you handle yourself and behave. At the end of the day when you are getting ready for bed, brushing your teeth (or tooth - if you are from West Virginia), you have to look in that mirror and answer for your progress. You either accomplished your goals or you didn’t. You have to look at it and face it down. The only way you can improve outcomes is to be 100% honest about the effort that you put in and the outcomes that resulted. Hearing “you did great!” even when you didn’t isn’t helping. Be honest with yourself. Make the changes you need to make and get better. 18 ADH_2020  Method 4: Physical Optimization - Sunlight I know that nerds burn easily when exposed to the sun. Plus, the Radiologist walks in shadow and moves in silence (to guard against extraterrestrial violence). Seriously - you only need like 5 mins a day. Your pineal gland demands it. I don’t care if it’s freezing cold outside - get your ass out there and look at the sun for 5 mins. Be mindful in the moment and play the standing outside in the sun game. Method 5: Physical Optimization - Sleep 1 have trained myself to sleep 4.5 hours a night by mapping and understanding my REM cycles. People will say they "can't do that. ” People use the phrase “can’t do that” when they really mean "I don't want to do that because it will hurt too much.” Callous your mind. This takes some effort and practice. If I get 3.5 hours sleep I feel terrible. I don’t really care about “feeling terrible.” A warrior does not complain of physical discomfort. The problem is I can’t concentrate. I also feel this way with 5.5 hours sleep. At 4.5 hours though... the Lion roars. The trick is to map your sleep patterns. There are apps that can do this. Alternatively, you can go full retard and buy a “sleep shepherd,” which is my endorsement if you really want an accurate map plus the added benefits of binaural beats. Take two weeks and create a sleep journal. What you are looking for is how long it takes you to go through two REM cycles. Then you can plot your bed time and wake up time to maximize productivity. If you do this right you can potentially get 4 extra hours a day to study. 19 ADH_2020  Method 5: Physical Optimization - Sleep - Continued Sleep Induction: Another component to getting the most out of your sleep is the ability to fall asleep rapidly. All that time you might be spending staring at the ceiling is time wasted. I recommend the use of a “sleep induction mat.” It’s basically a porcupine. This is most helpful if you have a “busy mind” - full of distracting thoughts. How this works: It’s a bunch of sharp (dull) plastic points. You take your shirt off and lay on them. It hurts. The pain distracts you from all the random shit you might be thinking about. Practice the self remembering exercise. In about 5 mins you will notice that it doesn’t hurt anymore. That is because your body is releasing a low level of endorphins. Sit up - roll the thing up - and go to sleep. Some people will tell you that it takes 30 mins to work. That's a bunch of baloney ~ 5 mins tops. But Prometheus?! The Codex Astartes Does NOT support this action! Every year I get at least one belligerent turbo nerd email quoting me sleep research and telling me that I must have the p.Tyr362 His mutation - a variant of the BHLHE41 gene - and that my advise to sleep deprive violates both the teachings of the Emperor Leto II Atreides and described will of the Emperor of Man as transcribed by the Imperial Ecclesiarchy / Adeptus Ministorum. Before the writing of the annual “I need my teddy bear and 10 hours of sleep email”- allow me to clarify my points: This is about getting a mental edge This is about getting a tactical advantage from weaponized will power It is possible to maximize your sleep efficiency through REM mapping I can do it - and so can other people (you may be one of them) Reduced sleep can be augmented with optimized nutrition, hydration, exercise etc... If my provided methodology (sleep mapping, diet, hydration, exercise, etc..), doesn’t work for you - consider the following: Alternative approach to overcoming fatigue: (Step 1) Make a fist with your brain (Step 2) Punch sleepy time in the face Uninitiated: How did you get all those cases right in conference this morning ? Lionhart Trained: 1 studied 3 hours before conference. I’ve been getting up early. Uninitiated: Oh... I “need” to get my 8 hours of sleep in. So, I’m gonna study 3 hours this evening. Lionhart Trained: 1 'll also be studying 3 hours... 3 additional hours this evening. 20 ADH_2020  Method 6: Physical Optimization - Diet The human body is designed to operate perfectly... in a world that existed 10,000 years ago. Despite what the primitive “rat brain” may tell you, sugar is the devil. Foosball, school, girls, and Ben Franklin are also the devil - but that is unrelated to this discussion. Avoiding highs and lows is key to optimal function. Avoiding IBS cramps and constant shitting is also ideal. I’m not going to endorse a particular diet by brand name. I’ll just say there is a lot of data showing that a Ketogenic diet (or something similar) helps to maximize mental function. Method 7: Physical Optimization - Movement You need 15 mins a day of movement. This can be actual alpha male gym stuff, or beta male yoga - but any form of movement works and is necessary to maximize your mental health. I will say this - the more vigorous your training the more sleep your body will require. It is super important that you move (especially during this stressful time in your life) - and I’m not suggesting that you avoid working out to sleep less — so don’t get it twisted. I’m instead advising you to adjust your study schedule to allow more sleep on nights after you have worked out super hard. Optimizing physical training and sleep management requires flexibility, patience, and balance. Having said that — don’t use exercise as an excuse to be weak. If you plan on hitting an hour long spin class, rolling 2 hours straight at an open mat, or doing 15 sets of squats — plan the night before to sleep 2 extra hours. No snooze buttons. Snooze buttons are the path to the dark side. Snooze buttons lead to fear. Fear leads to anger. Anger leads to hate. Hate leads to suffering. Discipline equals freedom —Jocko. Don’t touch that fucking snooze button. Also— don’t forget you can also use working out as a weapon against fatigue. The times of the day when you are the most tired... work out. Oh, and don’t listen to music when you work out (that shit is cheating). It is supposed to hurt - that’s the point. 21 ADH_2020  SECTION 6: Use of Energy Let’s switch gears and talk about specifics on how to plan a strategy and use resources. When to Begin Studying: Frat Answer: Most people put in a 6 month training camp. They will typically being aggressive studying starting in late December or early January in preparation for the June exam. I think the amount of time necessary to pass depends on how strong you are as a multiple choice test taker, how much studying you did in the first 2 years of training, the amount/quality of teaching at your training institution, and your own ability to retain trivia. My recommendation would be between 9 and 6 months. Any longer than 9 months and you risk forgetting the trivia you learned at the beginning of your training camp. I like the analogy of a bucket with a hole in the bottom. You pour water (knowledge) in the bucket and it slowly drips out the bottom. You want the bucket to be filled to the brim the morning of the exam. 9 Months = The upper limit of trivia retention 6 Months = Average 3 Month = You better be a trivia machine Less than 3 Months = Go ahead and register for the repeat exam. Now... having said that - this is a critical point: “Don’t just work longer hours” — ‘Work smart’ —i.e. Stay productive and don’t get distracted.” - Dan Pena This leads us to my next critical point: What to do Prior to Starting to Study: You need to come up with a game plan. The specifics of this plan is not something I can help you create because each one of you has unique social circumstances and backgrounds. Some of you have kids. Some of you have jealous wives / husbands. Some of you have program directors who will not give you one minute off service to study but will still throw you in the pillory if you fail. Whatever your social situation you need 3 things: (1) Somewhere quiet to study that is free of distractions. (2) Time in this ideal study environment (3) Resources to study (books, questions, videos, and Google). 22 ADH_2020 The Ideal Study Environment: There is a person inside you that does not want to study. This person doesn’t care that you will be humiliated if you fail. This person believes in nothing Lebowski. He/She only wants to eat, read celebrity gossip, watch internet pom, and sleep. When it comes to successful preparation this person is your greatest enemy. For me at least, it seems that dealing with this person (your inner hungry, sleepy, pom crazed, Justin Bieber fan) is like dealing with a meth addict. Don’t leave the meth lying around where he/she can see it. If he/she gets ahold of it... the study session is over. What is “the meth ”? It varies from person to person. It most cases it’s your fucking phone. Do NOT bring your phone into the study environment. If you must bring your phone (for child care reasons, etc...) then put it on a shelf on the other side of the room. Other Tips: Don’t show up hungry. Eat prior to going into the study environment. Avoid sugar as it will make you crash. Caffeine is your friend. If your religion forbids the use of caffeine - dig around in your sacred text for loop holes. Most major religions allow you to ask for forgiveness later. The best time to ask for forgiveness is after you pass the exam. How much caffeine? There is at least one paper that showed that small hourly doses of caffeine (0.3 mg per kg of body weight [approx 20 mg per hour] is optimal). Caffeine tablets - cut can help you keep this accurate. Stay away from energy drinks and all that bullshit - you want to keep the dose steady. Consider keto coffee (bullet proof coffee) or other coffee brands with high fat content to help improve bioavailability. No music in the environment. This feeds the lazy person inside you and is a distraction. I will listen to music prior to studying. Like a pro wrestler walk out song. “Replacement Killers” by the Crystal Method is my current suggestion. And I say this to the night. Let us not forget. There is hope. No “Study Buddies.” You need to be alone in this room. Your inner lazy person will try and small talk with your study partner’s inner lazy person. It will start out innocent with you asking them a legit questions about radiology / physics. 30 seconds later you will be chatting about Kardashians (or that reality tv show with the pro wrestlers girlfriends). If you must study in a public location, you should make it clear to your classmates that you don’t want to be interrupted - snarl at them. You should also bring ear plugs for when they start talking to each other. 23 ADH_2020 How Many Hours Per Day Should You Study: You need about 2-3 hours on weekdays, and 8-12 hours a Mad Man (Woman) day on the weekends. This is the minimum. The real Tactics answer would be “however much would kill you, minus Set your alarm for 2 am and one second.” study for 30 mins once a week. For me, studying early in the morning is superior to the evening. After work you are tired, your family is the most Why? Because everyone needy, and you are the most distractible. Most days when I else is asleep while you arc working hard. This kind of left work as a Resident I was angry about something. thinking is how you get an Usually one or more of my asshole Attendings having no edge - see Law 2. regard for my need to study. All that hate (although motivating) was also distracting. It’s hard to study when you are trying to plot revenge. I understand some people are just not wired for early morning studying, but it is ideal if you can make yourself do it. Along those lines...Sleep is for pussies. See prior discussion on optimizing your sleep. Stealing an hour during the day. Most programs have a noon and / or morning lecture. At this point in your training you know when these are useful and when they are a waste of time. I would have zero remorse about ditching a low yield lecture to study. If you feel bad for even one second just think about what will happen to you if you fail. If you do decide to ditch a lecture make it count. Have your hiding place / study environment picked out. Have your goals for what you want to get through clear. The more productive that hour is the less bad you will feel about doing it. “Morgen, morgen, nur nicht heute, sagen alle faulen leute. " — Roughly translated as “tomorrow, tomorrow, not today.... say all lazy people.” Never — Never — Never put off or delay an opportunity to study. Thinking “I’ll have time to study later” is a huge mistake. I want to encourage you to adopt the idea of Premeditatio Malorum - where you consider all the things that can go wrong in your day and fuck up your plans. Maybe your kid will get sick tonight, or you will have a pipe break in your apartment or who knows what the fuck can happen. Maybe your little sister will break up with her high school boyfriend and suck you into an unescapable whirlwind of teenage drama. Recognize that the world can fuck up your plans pretty easily. Never procrastinate. If you have a chance to do it now - then fucking do it. 24 ADH_2020 Resources: Essentials: Crack the Core Vol 1, Crack the Core Vol 2, Physics War Machine, Crack the Core Case Companion. Combat Ready - my new Q and A book. Highly Recommended: TitanRadiology.com / RadiologyRonin.com - Board Review Course and Clinical Mastery. Supplemental: Google Images - No single book can match the power of the internet. Q Banks: Last year I released a Q Bank via TitanRadiology. I’m hoping to improve and expand the question bank this year. Obviously that is going to be the one I’ll endorse. Regardless, my opinion is that more questions are better. I would do as many practice questions as possible which will likely mean using multiple commercial q banks. How To Use the Resources: Everyone is starting from a different place depending on your individual background and interests. Having said that nearly everyone has 5 tasks to accomplish: (1) Fill in the large holes. Everyone sucks at something. There are probably 3-4 sections (maybe more) that you feel particularly weak in. (2) Accumulation of Random Trivia. Even if you think you are strong in a certain subject there is almost certainly a laundry list of trivia that you don’t have available for recall. (3) Physics. Nearly everyone starts out knowing almost zero physics. (4) Non-Interpretive Skills. This is another topic that pretty much no one has any exposure to. (5) Biostats. You will have to review the basics on this as well. 25 ADH_2020 Suggested Strategy for the Clinical Portions: (1) Make a list of the subjects you suck the most at. (2) Read the corresponding sections / chapters in Crack. Read them slowly. Google image anything you’ve never seen before. (3) Watch the corresponding videos to these chapters on TitanRadiology. (4) Start at the beginning of Crack Vol 1 and work your way to the end of Vol 2. Don’t skip the Chapters you read already - this is your second time through those. Annotate and mark up the books. I’ve purposefully provided lots of room for extra notes. Also, the paper is not glossy for a reason - I did this so you can write in the books without smearing shit everywhere. (5) Start back at the beginning of Crack Vol 1. This time we are going to add practice questions. Pick a QBank, they are all pretty similar (mine is best obviously). Read a chapter in Crack (example Peds) then do the corresponding Peds questions. Make notes in the book as needed. Work your way all the way through the book. This process can be supplemented with the corresponding Titan Videos. (6) Start to switch over to 90% questions - 10% reading. Now is the time to read the Case Companion. You should be doing 150 + questions a day. Go ahead and make them random, that will simulate the exam. Practice Questions: Practice questions do two things for you. (1) They help expose holes in your knowledge. (2) They help you practice your timing and discipline. I think it’s important to backload questions until you have a foundation. There is no point in doing practice physics questions if you have never read a page of physics. It’s a total waste. Clinical radiology is the same way. Don’t mess with questions until you have read the chapter in Crack at least once. Once you have entered “phase 2” - which would correspond with step 6 above. It’s time to start doing questions with a timer. Average one minute per question. Practice your disciplined approach (reading the entire question, reading all the choices, never change your answer). You should be doing more and more questions every week leading up to the exam - revising the material as needed. In the volume 2 strategy chapter I discuss the “Genius Neuron. ” He (She) is your closest friend and you must learn to trust his/her advice. 26 ADH_2020 Learning Physics / Non-Interpretive Skills: There are two strategies. Both are equally valid depending on your personality. Strategy 1: Learn it all at once. Blocking out 6-8 weeks of your study schedule and just hit physics every day. Strategy 2: Ration it in with the clinical reading. For example if you study for two hours, 1 hour in physics, 1 hour in clinical. Regardless of which strategy you pick you should follow the same steps: (1) Read the War Machine cover to cover once. Titan videos may help solidify topics. If necessary google topics that remain confusing. (2) Start over and read each chapter - then do corresponding questions. (3) Continue to do practice questions to keep the material fresh. (4) Reviewing the ABR’s NIS source document will still be necessary (make sure you are using the most up to date version). Read the War Machine’s discussion first - it will likely make the document more digestible. The Last Month: (1) Most (90%) of your time should be spent on timed practice questions. (2) The other 10% you should spend preparing your high yield review. You should start by putting together a list of all the random trivia that you will forget immediately after the exam. This is a list of all the numbers, half-lives, photon energies, etc.. The back of the War Machine has a good start on this but you will likely want to add to it. The Last Week: (1) Continue doing practice questions. (2) Study your high yield numbers / trivia every day. Try and concentrate it to 1-2 pages of stuff you are having trouble remembering. (3) Review Biostats, and skim the ABR’s Non-Interpretive Skills study guide. The Morning of the Exam: Look at your highest yield notes (the 1 - 2 pages of trivia you have boiled down). Read it over and over and over again until they make you get rid of all your notes. 27 ADH_2020 When You Sit Down To Take The Exam: (1) Check to make sure your markers work. If you got a dud fix it now. You don’t want “dead marker rage” to make you drop a question mid exam. (2) Scribble down all the formulas and numbers you can remember on one of the dry erase boards. Six hours into the exam that information won’t be in your short-term memory any more. (3) Give yourself a vigorous scalp massage - like 30 seconds. This increases blood flow to the brain and reduces stress. Seriously, it really works. I learned this from Ivan Vasylchuk (Ukrainian Sambist, Merited Master of Sport, World Champion, and Winner of the SportAccord World Combat Games). **Don’t forget to do this on the second day of the exam also. The Night Between Exam Days: Anticipate the subjects that haven’t been tested yet and review your notes on those. Avoid drinking or socializing. This is war. The people in the hotel lobby aren’t your friends, those are the people trying to push you into the bottom 15%. You can be friends with them after you pass Plus, arguing over who missed what will only increase your anxiety. Avoid alcohol - even if you are “sure you failed.” A strong performance day 2 can resurrect you. In general, most people feel like they did terrible after day 1. Remember, it is all about how you did relative to you cohort. Study 2-3 hours. Don’t eat anything that will give you diarrhea. 15 minutes on the treadmill can be tremendously helpful to reduce stress. Get 6-8 hours sleep. 28 ADH_2020  SECTION 7: Weaponize your Will This last section is a discussion on how to weaponize your will power and stay motivated for the duration of the training camp. Attack by Fire 10-15% of people will fail this exam. You must beat those people to pass. No one has the right to beat you. 1 don’t care where you trained. I don’t care where you came from. No one has the right to beat you. When doubt seeks in you can go two roads. You can go to the left or you can go to the right. You may hear people say “failure is not an option.” This is silly, failure is always an option. Failure is the most readily available option - but it’s not the only option - it is a choice. You can choose to fail or you can choose to succeed. Self doubt and negative thoughts are the road to failure. I want to tell you this - as someone who prides himself on both physical and mental toughness - it is normal to feel that way sometimes. The vast majority of people reading this book are perpetual winners in life, and those kinds of people hate to admit weakness to others and to themselves. You are not your accomplishments. You are not your failures. You are you. Recognizing that about yourself gives you the power to overcome negative thought through the awesome power of hard work. Earn your victory. Deserve to win - the Gods of War will look favorably upon you. Don’t hold back. Go 100% the entire time. You may hear people say - “you look tired, you look exhausted.” The worst feeling in the world is losing and knowing that it was because you were lazy and didn’t put in the work. I’d much rather get beat knowing I did everything I could to be prepared. “You look tired, you look exhausted,” - yeah... you bet your ass I’m tired, that is the whole fucking point. My goal is always to be exhausted at the end of each day. You want to feel like you got hit by a fucking freight train. That’s the feeling I like. That’s how I know I’m giving my best effort. I train hard, I work hard, I fight hard, and I fight for victory. In any competition, I want only one thing and that is to leave with my hand raised, at the top of the podium, with the gold medal - and I make no apologies for that. You shouldn’t either. 29 ADH_2020 Tactical Dispositions - “Snarl More Prior to entering the study environment - find a mirror and make the ugliest face you can. Not a silly face. Not a sad face. A snarl. A good snarl can give you what the Bible calls a psychological edge. Vacuity and Substance Most people go through their lives trying to avoid pain. This is a mistake. You are competing in a high stakes contest. Pain is your friend. If you can endure more time in the study room relative to your opponents then you have an edge (Law 2). Once you understand this you won’t avoid pain anymore. Look for pain. Invite him in and have dinner with him. You don’t look for me pain.... I look for you. This is a fundamental concept for developing the Lion’s heart. If you want to get somewhere in life - start by taking stuff away. There is nothing you can add to your life that will make you stronger. Understanding this is something you can take with you the rest of your life. At an early age, I was fortunate to learn the truth about despair - that nothing tastes better than a bologna sandwich when you haven’t eaten for 3 days. There is a reason why a guy like Julio Cesar Chavez can win 87 boxing matches in a row, because the mother fucker grew up in an abandoned railroad car with his five sisters and four brothers. You think someone like that is gonna break when they get tired? Any luxuries that you are enjoying in your life - those aren’t making you stronger. Take stuff away. Maneuvering the Army Many of you have probably had fairly normal lives with loving families and friends. I imagine that could be a source of motivation. When you feel that you are too tired to study, or can’t motivate yourself to enter the study environment, think about them. Think about how much better things will be for them once you are making a real salary. Rise and Grind. 30 ADH_2020 Illusion and Reality For others, perhaps you have traveled a different path. Not everyone has enjoyed a life filled with good times and noodle salad. Some of us were born in the dark, molded by it. Now, you are after something. It could be revenge. It could be money. Or.... it could be something else. Vengeance is a powerful motivator. Think of all the people who have tried to stop you. Think of all the people who have mistreated you. Visualize their stupid ugly faces smirking and smiling when they hear you failed the exam. Let it boil you blood. Now picture those same people making a face like they smelled a fart when they hear you passed the exam. You will find that you aren’t tired anymore. You are ready to train. As a resident I went as far as putting a picture of one of my tormentors in my shoe. That way every step I took I was walking on this persons face. Feel free to try that 31 ADH_2020  SELF AFFIRMATION -A TOOL TO WEAPONIZE YOUR WILL- I have an oath that I read to myself -especially when I’m tired, as a tool to harness my will. I encourage you to modify the oath to make it yours. Hang it somewhere you can see it daily. Perhaps beside a picture of the person you hate the most in this world. Or... if you are less of a Sith and more of a Jedi - hang it beside a photo of the people you love. MY NAME IS (youR NAME HERE) AND THIS IS MY OATH IN SOUND MIND I MAKE THIS OATH. I DECLARE THAT I AM NOT PERFECT. I KNOW THAT THERE WILL BE CHALLENGES TO OVERCOME, BUT I SWEAR ON THE POWERS OF THIS UNIVERSE THAT I WILL FIGHT WITH ALL MY HEART, ALL MY STRENGTH, AND ALL MY SOUL TO OVERCOME. I WILL OUTWORK ALL HUMAN BEINGS THAT STAND IN FRONT OF ME. NO ONE WILL TRY AS HARD AS ME. THEY DO NOT HAVE MY HEART OR UNRELENTING DESIRE. I DECLARE THAT I WILL PERSIST WHEN OTHERS GIVE UP. I WILL ALWAYS BE HUNGRY FOR MORE. EVEN WHEN THINGS SEEM IMPOSSIBLE, I WILL NOT GIVE UP. TODAY I AM GOING TO WAR. NO ONE HAS THE RIGHT TO TAKE MY DREAMS FROM ME. I WILL SACRIFICE UNTIL I REACH THE TOP. NO TEMPTATION WITH SWAY ME. I CRAVE ONLY THE BLOOD OF THE ENEMY. MY HEART IS ON FIRE. NO MATTER HOW LOUD MY BODY SCREAMS, I WILL SCREAM LOUDER. I AM FOCUSED. I AM PREPARED FOR BATTLE. COME AT ME, I DARE YOU. I AM PREPARED FOR WAR. 32 ADH_2020 Despite these words, this page is intentionally blank. 33 ADH_2020  34 ADH_2020  PEDIATRICS PROMETHEUS LIONHART, M.D. 35 ADH_2020  SECTION 1: Skull & Scalp Craniosynostosis “Craniosynostosis” is a fancy word for premature fusion of one or several of the cranial sutures. The consequence of this premature fusion is a weird looking head and face (with resulting difficulty getting a date to the prom). Besides looking like a gremlin (or a cone­ headed extraterrestrial forced to live as a typical suburban human), these kids can also have increased intracranial pressure, visual impairment, and deafness. There are different named types depending on the suture involved - thus it’s worth spending a moment reviewing the names and locations of the normal sutures. Bones Fusion Fusion Involved Direction Order Metopic Front to First Frontal (frontal) Back (2-3 months) Frontal & Lateral to Coronal Second Parietal Medial Parietal & Lateral to Lambdoid Third Occipital Medial Back to Sagittal Parietal Fourth Front Sutures normally have a serrated (saw tooth) contour With early closure the suture will lose the serrated appearance - becoming more dense and sharp. Eventually the suture will disappear completely. For the purpose of multiple choice, you should think about synostosis (early closure) as likely syndromic - and focus your memorizing on this point. Having said that, sagittal and unilateral coronal synostosis are typically idiopathic 36 ADH_2020 Craniosynostosis Continued... “Plagiocephaly” Potential Source of Fuckery Pathology / Sub-type Trivia: This word basically means “flat.” You will see it used to describe unilateral coronal synostosis as “anterior plagiocephaly.” You will see it used to describe unilateral lambdoid synostosis as “posterior plagiocephaly. ” The problem is that many people use the word “plagiocephaly” to describe the specific entity of “deformational plagiocephaly” - which is just benign positional molding, not a pathologic early closure. On the following page, I’ll go into more detail on this. Just know you may be required to read the question writer’s mind when the word is used to differentiate between the benign and pathologic entities. Eyes are close together (hypotelorism) Ethmoid sinuses underdeveloped “Quizzical Metopic Medial part of the orbit slants up Trigonocephaly Eye” (frontal) Single suture synostosis most frequently appearance associated with cognitive disorders (growth restriction of the frontal lobes) Unilateral subtype is more common. Unilateral type causes the ipsilateral orbit to “Harlequin elevate, and contralateral frontal bone to Coronal Brachycephaly Eye” protrude “frontal bossing” * if unilateral. Bilateral form is Rare - should make you think syndromes (Borat's brother Bilo*). Least Turricephaly Tall Cranium (oxycephaly, acrocephaly) Lambdoid Common (if bilateral) See Next Page for Unilateral Discussion Form Long, Narrow Head. Looks like an upside-down boat. Scaphocephaly Most Usually the kids have a normal IQ Sagittal or Common Usually the kids do NOT have hydrocephalus Dolichocephalic Form Associated with Marfans (both are tall and skinny). *For the purpose of this text, Borat's brother Bilo is presumed to have syndromic mental retardation / developmental delay. Not iatrogenic encephalopathy related to the intracranial placement of a red haired woman's tooth - as therapy for demon induced epilepsy - which is suggested in some reports. 37 ADH_2020  THIS vs THAT: Positional Plagiocephaly vs True Unilateral Lambdoid Synostosis Infants that sleep on the same side every night If this is bilateral think underlying develop a flat spot on the preferred dependent Rhombencephalosynapsis area of the head (occipital flattening). Onset: Weeks After Birth Onset: Birth Ipsilateral Ear: Anterior Ipsilateral Ear: Posterior / Inferior Frontal Bossing: Ipsilateral Frontal Bossing: Contralateral Most common cause of an abnormal Rare as Fuck skull shape in infant Management is conservative Management is Surgery (sleep on the other side for a bit) NEXT STEP; Trivia For the purpose of multiple choice, there are numerous Outside of the jungle (or the year 1987), the random bone buzzwords diagnosis of synostosis is going to be made with that are supposed to elicit CT + 3D. If asked what test to order I would say the reflexive diagnosis CT with 3D recons. Having said that, they could NF-1 in your brain when show you a skull plain film (from 1987) and ask you hear / read them. you to make the diagnosis on that. The more common ones include: If the test writer was feeling particularly cruel Absence / Dysplasia of the Greater and bitter he/she could show the diagnosis Sphenoid Wing, with ultrasound. In that case, remember that Tibial Pseudoarthrosis, a normal open suture will appear as an Scoliosis, and uninterrupted hypoechoic fibrous gap Lateral Thoracic Meningocele. between hyperechoic cranial bones (Bright - Dark - Bright, Bone - Suture - Bone). I’d like to add “bone defect in the region of the lambdoid suture ” or the “asterion Although certain MR gradient sequences can defect" to that list of reflex generators. be used, MRI has traditionally been considered unreliable in identifying sutures individually. It’s rare and poorly described - therefore potentially high yield. 38 ADH_2020 Clover Leaf Skull Syndrome Also referred to as Kleeblattschädel for the purpose of fucking with you Contrary to what the name might imply - this complex deformity is not associated with an increased ability to hit green lights, reliably find good parking spots, or win the lottery. I think that’s because the shape is more 3 leaf clover, and not 4 leaf. One might assume, a head shaped like a 4 leaf clover would probably be luckier. Instead, this deformity is characterized by enlargement of the head with a trilobed configuration, resembling a three-leaved clover. Results from premature synostosis of coronal and lambdoid sutures (most commonly), but often the sagittal closes as well. Hydrocephalus is a common finding. Syndromic Associations: Thanatophoric dysplasia, Apert syndrome All the sutures arc (severe), Crouzon syndrome (severe) closed except the metric and squamosal Trivia Additional Craniosynostosis Syndromes; Most of the time (85%) premature closure is a primary (isolated) event, although it can occur as the result of a syndrome (15%). The two syndromes worth having vague familiarity with are Apert’s and Crouzon’s. Brachycephaly (usually) Apert’s Fused Fingers (syndactyly) - “sock hand” Brachycephaly (usually) 1 st Arch structures (maxilla and mandible hypoplasia). Crouzon’s Associated with patent ductus arteriosus and aortic coarctation. Short central long bones (humerus, femur) - “rhizomelia” Chiari I malformations 3: ~70% of cases 39 ADH_2020  THIS vs THAT: Skull Markings Convolutional Markings Copper Beaten Luckenschadel - ''Lacunar'' Normal gyral impressions on The same thing as convolutional Oval, round, and finger shaped the inner table of the skull. markings (the normal gyral defects (craters) within the impressions), just a shit ton inner surface of the skull more of them. Different than Copper Beaten You also see them along the in that: You see them primarily during anterior portions of the skull not (A) They aren’t gyriform. normal rapid brain growth (age just the posterior. (B) They aren’t related to 3-7). increased ICP. (C) They are usually present at Usually mild and favors the Think about things that cause birth. posterior skull. increased intracranial Instead they are the result of If you see them along the more pressure. defective bone matrix. anterior skull then you should think about a “copper beaten” Classic examples: Classic Association: skull from the increased Craniosynostosis Obstructive Hydrocephalus Chiari II malformation / intracranial pressure. Neural Tube Defects. Lytic Skull Lesions: Lytic skull lesions in kids can come from a couple of different things (LCH, Infection, Mets, Epidermoid Cysts, Leptomeningeal Cysts, etc...). The two I want you to focus on are LCH and the Leptomeningeal Cyst (which I will discuss later in the chapter). LCH (Langerhans Cell Histiocytosis) - Too many fucking dendritic cells - with local invasion. It is a sorta pseudo malignancy thing. Nobody really understands it.... For the purpose of the exam think about this as a beveled hole in the skull. The skull is the most common bone involved with LCH. It is a pure lytic lesion (no sclerotic border). The beveled look is because it favors the inner table. It can also produce a sequestrum of intact bone (“button sequestrum). Gamesmanship: If they tell you (or infer) the kid has neuroblastoma - think about a met. 40 ADH_2020 Parietal Foramina These paired, mostly round, defects in the parietal bones represent benign congenital defects. The underlying cause is a delayed or incomplete ossification in the underlying parietal bones. They can get big and confluent across the midline. Supposedly, (at least for the big ones - > 5 mm) they are associations with cortical and venous anomalies. Wormian Bones In technical terms, there are a bunch of extra squiggles around the lambdoid sutures. “Intrasutural Bones” they call them. These things are usually idiopathic - however, if you see more than 10 you should start thinking syndromes. Gamesmanship: < 10 = Idiopathic > 10 = First think Osteogenesis Imperfecta > 10 + Absent Clavicle = Cleidocranial Dysostosis There is a massive differential, but I would just remember these “PORK-CHOP” Pyknodysostosis Osteogenesis Imperfecta Rickets Kinky Hair Syndrome (Menke's / Fucked Copper Metabolism) Cleidocranial Dysostosis Hypothyroidism I Hypophosphatasia One too many 21st chromosomes (Downs') Primary Acro-osteolysis (Hajdu-Cheney) 41 ADH_2020 Dermoid / Epidermoid of the Skull In the context of the skull, you can Epidermoid Dermoid think about these things as occurring from the congenital misplacement of Only Skin Skin + Other Stuff cells from the scalp into the bony Histology (Squamous Like Hair Follicles, Epithelium) Sweat Glands Etc.. calvarium. Age of Present between Typically have an The result is a growing lump of tissue Onset age 20-40 earlier presentation (keratin debris, skin glands, etc...) Parietal Region is Tend to be midiinc. creating a bone defect with benign Location Most Common The skin ones tend to appearing sclerotic borders. (“behind the ears ”) be around the orbits. There are a few differences between Associated with Encephaloceles - the two subtypes that could be especially when potentially testable (contrasted midline masterfully in the chart). - More Heterogeneous, - Calcifications Although, I suspect a “what is it?’’ CT CSF Density (internal or peripheral) type question is more likely. As such, may be present look through some google image T1 Variable, T1 Bright, examples to prepare yourself for that MRI T2 Bright, T2 Bright, NO Enhancement +/- Wall Enhancement contingency. Congenital Dermal Sinus Usually when people talk about these things they are referring to the spina bifida style midline lumbosacral region defects. However, we arc going to stay focused on the skull / face. The two classic locations for dermal communications with the dura are the occiput and the nose. Both of which are classically midline, and can be associated with a dermoid cyst. For gamesmanship, consider a sinus tract anytime you see a cyst in these locations. Sinus tracts may or may not have associated dermal or intraosseous cysts. Cysts may or may not have sinus tracts. 42 ADH_2020  THIS vs THAT: Scalp Trauma There are 3 scalp hematoma subtypes. Because the subtypes are fairly similar, there is a high likelihood a sadistic multiple choice writer will attempt to confuse you on the subtle differences - so let’s do a quick review. Caput Subgaleal Hemorrhage Cephalohematoma Succedaneum Subcutaneous Deep to the Aponeurosis Under the Periosteum Hemorrhage Location (between aponeurosis and (skin of the bone) (superficial to periosteum) the aponeurosis) Suture NOT limited by Limited by suture lines NOT limited by Relationship suture lines (won't cross sutures) suture lines Outer border may calcify as a rim Covers a much larger area and leave a deformity - sorta like Trivia than a cephalohematoma a myositis ossificans. Usually requires no intervention Potentially life-threatening (resolves within a few weeks) Requires no - rapid blood loss. intervention Can get super infected (E. Coli). Complications Often not seen until 12-72 Abscess would require drainage. (resolves within a few days) hours post delivery. Can cause skull osteomyelitis. Prolonged Cause Vacuum Extraction Instrument or Vacuum Extraction Delivery 43 ADH_2020 Skull Fractures Accidental (and non-accidental) head trauma is supposedly (allegedly, allegedly) the most common cause of morbidity and mortality in children. As you might imagine, the pediatric skull can fracture just like the adult skull - with linear and comminuted patterns. For the purpose of multiple choice, I think we should focus on the fracture patterns that are more unique to the pediatric population: Diastatic, Depressed, and “Ping-Pong” Diastatic Fracture: This is a fracture along / involving the suture. When they intersect it is usually fairly obvious. It can get tricky when the fracture is confined to the suture itself. The most common victim of this sneaky fracture is usually the Lambdoid, followed by the Resident reading the case on night float...with Attending backup (asleep in bed). How does one know there is traumatic injury to a suture? Classically, it will widen. This is most likely to be shown in the axial or coronal plane so you can appreciate the asymmetry (> 1 mm asymmetry relative to the other side). Depressed Fracture: This is a fracture with inward displacement of the bone. How much inward displacement do you need to call it “depressed”? Most people will say “equal or greater to the thickness of the skull.” Some people will use the word “compound” to describe a depressed fracture that also has an associated scalp laceration. Those same people may (or may not) add the word “penetrating” to describe a compound fracture with an associated dural tear. Will any of those people be writing the questions? The dark side clouds everything. Impossible to see the future is. Ping Pong Fracture: This is actually another subtype of depressed fracture but is unique in that it is a greenstick or “buckle” type of fracture. Other potentially testable differences include: Outcomes: Ping Pong fractures typically have a favorable / benign clinical outcome (depressed fractures have high morbidity). Etiology: Diastatic and depressed fracture types usually require a significant wack on the head. Where as “ping pong” fractures often occur in the setting of birth trauma (Mom’s pelvic bones +/- forceps). Imaging Appearance: Ping Pong fractures are hard as fuck to sec. To show this on a test you’d have to have CT 3D recons demonstrating a smooth inward deformity. You could never see that shit on a plain film. I can’t imagine anyone being a big enough asshole to ask you to do that. Hmmm.... probably. Unlike linear fractures (which usually heal without complication), Normal depressed fractures often require surgery. Some general indications Fracture Suture for surgery would include: > 3 mm < 2 mm Depression of the fragments > 5mm (supposedly fragments more than 5mm below the inner table are associated with dural tears), Wide Center Equal Width Epidural bleed “Darker” “Lighter” Superinfection (abscess, osteomyelitis) Straight “Form” (cosmetic correction to avoid looking like a gargoyle), Line, with Squiggly Line, with “Function” (if the frontal sinus is involved, sometimes they need Angular Curves to obliterate the thing to avoid mucocele formation). Turns 44 ADH_2020  Leptomeningeal Cyst -“Growing Skull Fracture” A favorite of board examiners since the Cretaceous Period. Typical Pathogenesis: - Step 1: You fracture your noggin, AND tear the underlying dura. - Step 2: Leptomeninges herniate through the tom dura into the fracture site. - Step 3: Over time (a few months) CSF pulsations progressively widen the fracture site and prohibit normal healing. - Step 4: You know you shouldn’t, but you just can’t resist the urge to poke your own brain through the now cavernous cranial defect. - Step 5: The poking triggers a powerful hallucinogenic experience. You have a telepathic conversation with a room filled with self transforming elf machines. You are overwhelmed with tremendous curiosity about exactly what/ who they are and what they might be trying to show you. - Step 6: You develop epilepsy from poking your brain too much. Or was it not enough? - you can’t remember Sinus Pericranii A rare disorder that can be shown as a focal skull defect with an associated vascular malformation. The underlying pathology is a low flow vascular malformation - which is a communication between a dural venous sinus (usually the superior sagittal) and an extra cranial venous structure via the emissary veins. Most likely way to show this: (1) MRI - with some type of vascular sequence - post contrast or MRA/TOF. (2) CT showing the skull defect - wanting a next step (ultrasound or MRI to demonstrate the vascular component). 45 ADH_2020 Non-Accidental Trauma (Abusive Head Trauma) Although car wrecks and falls account for the majority of skull fractures in children, there still remains the timeless truth — some people just can’t take screaming kids. For the purpose of multiple choice, the follow clues should make your spider-sense tingle. Inconsistent History: GAMESMANSHIP: “My 7 month old wrecked his bike ” Subdurals have a stronger association with NAT Subdural Hematoma relative to epidurals. Think about vigorous shaking (trying to get that last drop of ketchup Retinal hemorrhage out of the bottle) tearing bridging cortical veins. DAI / Parenchymal Contusion “Look High, Look Low” Cerebral Edema, Stroke - Sneaky Ways to Suggest NAT - (less specific but still worrisome) - Look High: Thrombosed (hyperdense) cortical vein at the vertex Depressed Skull Fx, or Fracture Crossing Suture Line - Look Low: Retroclival hematoma (thin (less specific but still worrisome) hyperdense sliver in the pre-pontine region) - Look Lower: Edema within the cervical soft tissues Retroclival Hematoma Extra Axial Fluid Chronic Subdural Epidural Prominent CSF Spaces (CSF Density) Below the Medial Displacement Cortical veins are Above the Tectorial Tectorial of Bridging Vein Membrane Membrane (sometimes smashed and adjacent to the inner table not well seen) Usually Unilateral. If Bilateral Usually Usually symmetric Asymmetric in Size. *More on NAT later in the chapter. 46 ADH_2020  SECTION 2: Brain - Select Topics Disclaimer: Brain tumors , cord tumors, and a bunch of other random Peds Neuro pathologies arc discussed in detail within the Neuro chapter found in volume 2. The same is true for congenital heart, certain GU, GYN, and MSK topics - found within their dedicated chapters. If you find yourself saying “Hey! What about that thing? This asshole is seriously not going to talk about that?” Relax, I split things up to reduce redundancy and cluster things for improved retention. Enlarged extra-axial fluid spaces: THIS vs THAT: Extra-axial fluid spaces arc considered enlarged if they are BESSI vs Subdural Hygroma greater than 5 mm. BESSI is the name people throw around for “benign enlargement of the subarachnoid space in infancy. BESSI - Cortical veins are adjacent to the inner table - they The etiology is supposed to be immature villa (that’s why you are usually seen secondary to grow out of it). enlargement of the subarachnoid spaces (positive cortical vein BESSI Trivia: sign) Subdural - Cortical veins are It’s the most common cause of macrocephaly, displaced away from the inner Typically presents around month 2 or 3, and has a strong table - they are often not seen male predominance. secondary to compression. Typically resolves after 2 years with no treatment, Enlarged There is an increased risk of subdural bleed - symmetric either spontaneous or with a minor trauma. This subarachnoid subdural is usually isolated (all the same blood spaces age), which helps differentiate it from non­ favoring the accidental trauma, where the bleeds are often of anterior aspect different ages. of the brain (spaces along Trivia - Pre-mature kids getting tortured the posterior on ECMO often get enlarged extra-axial aspect of the brain are spaces. This isn’t really the same thing typically as BESSI but rather more related to fluid normal). changes / stress. Brain parenchyma is normal and there is either normal ventricle size or very mild communicating hydrocephalus. Communicating meaning that all 4 ventricles are big. 47 ADH_2020 Periventricular leukomalacia (Hypoxic-