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 Neuroasdestiny : step 3 Journey  

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I love prep4usmle. This web have given me such enormous motivation and stratergies. After trying other paths for years, I realized that I cannot forget my dream to be an humanized neurologist.
Today I will start USMLE step 3 examination with this system.
1. Jason's FP review
2. Fischer'sMTB
3. Kaplan step2CK
4. Information from internet

combine each to be concept notes here.


Be back after 2 years

I am on tract of neurology residency training in my hometown.
This time the purpose of passing USMLE step 3 is very clear, not just a dream.
The stratergy has been change a bit, I decided to use only two materials.

1. UWorld MCQ+CCS
2. Ficher MTB 2013
3. Chunking system (Thanks for Coursera -learning how to learn)
Even if I have full time work as a residence - at least 1 chunk of knowledge/day ^_^

Edited by gpatama on Oct 19, 2014 - 8:46 PM


Ipecac using is always wrong

- Alkaloid based emetic inducer
short term SE = irritate GI mucosa + trigger CTZ
Long term SE = myopathy and cardiac problems

- Once recommended by the American Academy of Pediatrics (AAP) as a first aid for poisoning. However, since 2003 guideline showed ipecac use is not effective and even interfere with other treatment.

- misuse caused death of Bullemia singer- Carpenter

Edited by gpatama on Feb 17, 2012 - 6:56 PM


Gastric larvage is almost wrong.

- No later 1.5 hrs -> No benefit and harm (push pill fragment beyond pylorus)
- No more than 5 litrs
- No for acid, alkaline

- pulmonray aspiration -> rarely use only if antidote not work and need intubation


Charcoal is almost right for overdose "have no harm"

- decontaminant by absorp the substance to its surface and it cannot be digested.
- Sorbitol combine with Charcoal for shorten time to pass charcoal out from GI tract
- Not give sorbitol to children and who has hx fructose intolerant to avoid exessive fluid loss
- To avoid interfere: Give charcoal before GI antidote ie. Acetyl cysteine
- Heavy metal (eg. Iron Lithium), Ethanol, Petrolium are less absorp by charcoal


Edited by gpatama on Feb 18, 2012 - 5:56 PM


Anthrax is not spread person to person

-Infected by Anthrax spore from Animal or Bioterrorism
-2001. Anthrax was deliberately spread through powder in letters caused 22 infected and half of them death from lung infection.
- Treat by quinolone (eg. ofloxacin) and Doxycyclin


I like the ur thread..i'll also input more qs for discussions. keep it up !


Many thanks Nishi - I have time to review only during weekend but I will try to keep it up regulary.

TCA always need EKG

TCA is lipophilic -> metabolite by liver not by kidney

- Antihistamin effect is most common
-> drowsy

- Alpha-1 agonis is common
-> hypotension

- Anticholinergic (vagolytic) effect is common
-> Sinus tachycardia , not harmful
-> Seizure , Rx by BZD not phenobarb that also anticholinergic

- Inhibit fast sodium channel is the most concerned
-> RBBB block is sensitive sign
-> EKG that is indication for Sodium bicarb
- widen QRS
- Slurr S wave in lead I, aVR

Source :Mathew D Hutchinson et al,Tricyclic antidepressant poisoning, Uptodate website

Attached Files:
TCA.jpg (41 KB, 8 downloads)

Changing system:

Today I had chance to review our friend's exam experience as well as a guidance section of Kaplan Q book. I will divide my preparation into two phases

Phase I : study content
1. Jason FP : still be a good educational guide.
2. Use the Kaplan pocket guide as the main review book instead MTB ( some people complain its' mistakes and too heavy )
3. Internet source will stick with "Uptodate" ( My U have subscribed) since it is pretty reliable and provide clear explaination.
Phase II : practice questions
I like step 3 style defined by Kaplan Q book " Practice paraphrasing - applying with handful fact - if you get it, answer will come up in your mind even no seen options.
1. Kaplan Q book
2. UW esp CCS part
this phase I definitely need study partner

Try to use them active as much as I can
Till you feel "COMFORTABLE" with Qs
Expect date of examination before May 2013

Edited by gpatama on Mar 03, 2012 - 7:43 AM


gamma hydroxybutyrate (GHB) : Get Her to Bed

- Pathognomonic = alternating agiate + tachy /coma + brady
- aka liquid ectacy, GABA analogue
: date rape : because no test, no smell, cause amnesia, loss muscle control ( myoclonus is common)
- DDx form agitate + tachycardia
= Sympathetic stimulant [sweating] =Cocaine,Amphetamine, MDMA, Ectacy,LSD
- DDx from confusion + tacycardia
= Anti cholinergic [dry flush] = TCA
-DDx from coma + bradycardia
= Opioid

wikipedia summarize for Toxidrome




C-spine injury  Need Exclude ALL of US

 NEXUS Low-risk Criteria (NLC)

  1. Absence of posterior midline cervical tenderness
  2. Normal level of alertness (GSC full 15, Hx of brief cons loss is OK)
  3. No evidence of intoxication
  4. No abnormal neurologic findings
  5. No painful distracting injuries (eg. ankle sprain)

     This criteria were developed from large multicenter observational study with NPV 99.9 percent (95% CI 99.8-100)


Edited by gpatama on Mar 03, 2012 - 7:42 AM


Methanol toxic by acid (it's alc dehy product)

- wide gap metobolic acidosis
 Anion gap =  Na - ( Cl + HCO3) > 12

- Cause of high osmolar gap

Ingestion -> Methanol, Ethylene glycol
Lactic acidosis


MUDPILES..All with met acidosis among them methanol,ethanol,ethylene glycol with high anion gap


Thank you for your addition Nishi smiling face


Enjoy preparing the exam - no matter the matching will be, at least, " I did it":

After reading several topics regarding hard to find matching for old grad ( > 5 years graduation) , it discourage me for a while.

However, no matter what happened, it still worth to take step3 and try matching once.
If I do it, I got some life lesson and move forward without any regret.
If I don't , I will only keep asking myself "what if...".



Not treat beta-blocker overdose with adrenaline

- Stepwise treat beta blocker overdose induce bradycardia.

Atropine (usually not sufficient)
Calcium chorlide

These treatments act via increase intracellular Ca+  or cAMP
( Therefore these also use for Ca channel block overdose)

However, adreanline is the last choice since it need high dose to achieve therapeutic effect so high adverse effect from unopposed alpha constriction 

Edited by gpatama on Mar 15, 2012 - 4:16 AM


Nystagmus ddx Peripheral vs Central vertigo:
Peripheral  : Point ( unilateral - horizontal wink and Positional 
Central      : Chaotic (multidirection esp Vertical wink and Constant 


Nystagmus represent swaying of eye due to imbalance.

Balance of eye influence by eyes mucle tone, visual and vestibular

Muscle tone : Naturally, more eyes deviate from neutral, more likely to slowly sway back to central.

Visual : - It is non-pathologic visual mechanism  move away from pathologic vestibular side to compensate eye fixation. - also called "reflex optic fixation"

Vestibular : nystagmus will be illicit when head shaking or Dix-hallpike manuver.

-> Therefore when patient with BPPV who has problem in Left ear when he were role to Left we will see fast movement of both eyes point to Right..and when he stand up to walk he sway to Left.

Central lesion, otherwise, affect sparcely so it tend to be chaotic and unable to suppress nystagmus by visual fixation


John Patten. Neurological differential diagnosis 2nd ed. p 99-102 

Edited by gpatama on Mar 18, 2012 - 4:19 PM


this is nice. I was looking for this!
Howz ur studies going?


Thank for your kind words Nishi, and please forgive me for my shaky English.

My prep substantially interfered by routine work.  Anyway, do my best smiling face

I will definitely need a study partner to enhance study effectiveness.

How about your prep smiling face   I am sure you are very in good position.


no probs..keep in touch!!


A man 32 yo had no known underlying comes with Rt. hemiparesis for 2 weeks comfirmed by CT found Lt.lacuna infarction. HIV test negative. Serum VDRL positive, TPHA positive. He was LP and CSF profile shown as following

RBC 0, WBC 20 Lymp 90% protein 80 mg/dl glucose 75 mg/dl (serum BS =110)
CSF bacterial culture and VDRL are pending

what should do next ?

A. Start Ceftriazone 2 mg IV q 12 hrs
B. Start Acyclovir 500 mg IV q 8 hrs
C. Start Benzathine Peniciline 4 milion u q 4hrs
D. Start Asiprin 81 mg per day


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