Neurology — USMLE Step 3 Practice
Neurology questions on USMLE Step 3 cover stroke management, seizures, headache syndromes, movement disorders, and dementia. Rapid recognition of time-sensitive emergencies like ischemic stroke and status epilepticus is critical.
Frequently Asked Questions
What is the tPA window for ischemic stroke on USMLE Step 3?
IV alteplase (tPA) can be given within 3 hours of symptom onset in most patients, and up to 4.5 hours in selected patients (age <80, no prior stroke + diabetes, no anticoagulant use, NIHSS <25). CT head without contrast must be done first to exclude hemorrhagic stroke.
How do you manage status epilepticus?
First-line: IV lorazepam (0.1 mg/kg). If seizures persist after two benzodiazepine doses, give IV fosphenytoin, valproate, or levetiracetam. Refractory status epilepticus requires intubation and propofol or midazolam infusion. Check glucose immediately in all seizing patients.
What features distinguish tension headache from migraine on Step 3?
Tension headache is bilateral, pressing/tightening, mild-moderate severity, not aggravated by activity, without nausea or photophobia. Migraine is unilateral, throbbing, moderate-severe, worsened by activity, with nausea and photo/phonophobia. Triptans are first-line for acute migraine; NSAIDs and aspirin work for both.
What is the classic presentation of Parkinson disease on Step 3?
Parkinson disease presents with resting 'pill-rolling' tremor, cogwheel rigidity, bradykinesia, and postural instability. Levodopa/carbidopa is the most effective treatment. Dopamine agonists (pramipexole, ropinirole) are used for younger patients to delay levodopa initiation.
How do you differentiate Alzheimer dementia from Lewy body dementia?
Alzheimer disease presents with gradual memory loss as the earliest symptom. Lewy body dementia features visual hallucinations, REM sleep behavior disorder, parkinsonism, and fluctuating cognition. Lewy body dementia patients are exquisitely sensitive to antipsychotics, which can cause severe parkinsonism — avoid them.
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