10 USMLE Neurology Questions with Answers and Explanations (Set 1)

These 10 USMLE neurology practice questions cover seizures and status epilepticus, movement disorders, brain tumors, meningitis, brainstem and spinal cord lesions, dementia and conversion disorder. Each question includes the correct answer and an explanation.

Written by Dr. Ray Makar, MD, author of the Repeated USMLE Questions eBook series.

Prefer video? Watch daily USMLE case questions on MedFocus by Dr. Ray on YouTube.

How to use this page: read the question, pick your answer, then tap Show Answer and Explanation.

Questions

Question 1. A 10-year-old boy is brought to the emergency room by his mother due to a long active seizure. He was hospitalized two months ago for status epilepticus and was prescribed valproic acid. What is the first step of action?

A- Intravenous injection of haloperidol
B- Intravenous fluids
C- Airway stabilization and 100% oxygen
D- Gastric lavage
E- Electroencephalogram (EEG)

The first step of action for any patient in status epilepticus is to restore an airway, part of the ABCs (Airway, Breathing, Circulation). Intravenous anticonvulsant and fluids should be administered after that. This patient was diagnosed with epilepsy and is taking treatment so, no need for EEG. Gastric lavage should be done in cases of seizures caused by ingestion of toxic substance which is not the case here.
The correct answer is C

 

Question 2. A 36-year-old man comes to the office for evaluation of involuntary movements of his hands and feet. These movements developed gradually over the past 3 years. He is otherwise in a good health and takes no medication. He does not smoke or drink alcohol. He does not drink any caffeinated beverages or use any recreational drugs. His family noticed recent personality changes over the same period. On examination, there are abnormal involuntary movements of his hands with no certain pattern. He walks in dancing like-movements that make him almost losing his balance. Mental status examination shows abnormal low score. What is the most likely diagnosis of this patient?

A- Parkinson’s disease
B- Creutzfeldt-Jakob disease
C- Tourette’s syndrome
D- Drug-induced tremors
E- Huntington’s disease

Dancing-like involuntary movements with no pattern are characteristic of chorea. The patient age, gradual development of symptoms and abnormal mental status suggest Huntington’s disease.
The correct answer is E

 

Question 3. A 56 year old man is taken to the emergency room after having grand mal seizure during a staff meeting. He has no history of seizure but he complains lately of recurrent headaches in the morning and decrease in intensity later in the day. Laboratory investigations and imaging studies are performed. Which of these tests will confirm the diagnosis of glioblastoma multiforme?

A- Brain biopsy
B- CSF analysis
C- Head CT scan
D- MRI of the brain

All tests would suggest the presence of occupying lesion in the brain but the only confirmatory test is the brain biopsy taken during operating on the tumor. It is a common question in the USMLE and it is a tricky one. You should read the question carefully and know the difference between regular primary test and confirmatory test. In this case the next test would be head CT scan but it is not confirmatory and eventually it is not the correct answer.
The correct answer is A

 

Question 4. A 5-year-old boy is brought to the ER by his mother. He has fever, cough, lethargy, headache and neck pain. On examination, his temperature is 103.2 F, his neck is rigid and tender and Kernig sign is positive. CSF is clear and significant for glucose 60 mg/dL, protein 80 mg/dL, no bacteria or pus cells and lymphocytes count is 70%. What is the most likely causative organism?

A- Echovirus
B- Neisseria Meningitidis
C- Streptococcus Bovis
D- Streptococcus Pneumonia
E- Staphylococcus Aureus

History and clinical picture suggest meningitis. CSF analysis suggests viral infection rather than bacterial. Echovirus is the only choice that most likely the causative organism in this case.
The correct answer is A

 

Question 5. A 73-year old man is brought to the emergency room for dizziness and nystagmus. Examination reveals loss of sensation on the left side of his face and the right side of his body. He has hoarseness of voice and drooping of his left eyelid. The left side of his face is drier than the right side. He is referred for CT scan on his head. What is the site of lesion responsible for hoarseness of this patient?

A- Inferior cerebellar peduncle
B- Spinal nucleus of fifth cranial nerve
C- Nucleus Ambiguus
D- Lateral spinothalamic tract

Nucleus ambiguus contains the cell bodies of the nerves that innervate soft palate, larynx and pharynx. Lesions of the nucleus ambiguus affect one or more of nerve supply to these organs. Hoarseness of voice in this case is most probably due to defect of the innervation to the larynx caused by lesion of the nucleus ambiguus.
The correct answer is C

 

Question 6. A 73-year-old man with a history of benign prostatic hyperplasia (BPH) presents to the emergency room complaining of repeated falls. His wife admits that during the past 3 weeks he has had unsteady gait, urinary incontinence and memory disturbances. His medical, surgical and family histories are unremarkable. He has never smoked or taken any recreational drugs. He drinks alcohol socially. His laboratory tests are all normal. A CT scan of the head shows slightly enlarged ventricles and slightly compressed gyri. What is the most likely diagnosis of this patient’s condition?

A- Normal pressure hydrocephalus
B- Alzheimer’s disease
C- Middle cerebral artery stroke
D- Anterior pituitary adenoma
E- Trauma to the head due to elderly abuse

This is a typical presentation of normal pressure hydrocephalus. It is characterized by unsteady gait, urinary incontinence and dementia. The combination of these symptoms is diagnostic of this condition. Other options are characterized by one or two of these symptoms and other signs as well. A CT scan is always performed in old age with similar symptoms to exclude hematomas and confirm the diagnosis.
The correct answer is A

 

Question 7. A 69-year-old man presents to the clinic with his wife for evaluation of his memory problem. His wife tells you that her husband has begun to forget recent events insidiously since last year. He forgets recent conversations and recent appointments. He is no longer able to manage his checkbook and daily budget as he used to do. He has no history of general medical condition and he only takes baby aspirin daily. His examination is normal. Mini-Mental Status Examination reveals prominent memory loss. MRI shows a few areas of cerebral atrophy. Which of the following is the most likely diagnosis?

A- Old age dementia
B- Alzheimer’s disease
C- Vascular dementia
D- Lewy body dementia
E- Creutzfeldt-Jakob disease

This patient has an insidious history of disturbed memory and difficulty with daily activities. Progressive dementia as well as gradual difficulty in daily life activities is a common feature of Alzheimer’s disease. MMSE and MRI are also consistent with this diagnosis. The patient is not too old and there are no other symptoms or previous medical conditions that suggesting any of the other choices.
The correct answer is B

 

Question 8. A 17-year-old male student presents to the clinic with episodes of staring with lip smacking. He reports that he became unresponsive when he has these episodes. These episodes last for 1-2 minutes and he feels confused when he regains consciousness. General, neurological examinations and EEG are normal. What is the most likely diagnosis?

A- Absence seizure
B- Simple focal seizure
C- Complex focal seizure
D- Myoclonic seizure
E- Tonic-clonic seizure

This is a case of complex focal seizure which is characterized by loss of consciousness accompanied by doing things such as gag, laugh, cry or smack patient’s lips. It takes a few minutes to awake. It is different from simple focal seizure and absence seizures in loss of consciousness and longer time. Myoclonic and tonic-clonic seizure are causing jerky movements.
The correct answer is C

 

Question 9. A 28-year-old man presents to the emergency room after a bar fight in which he was shot. He is mildly distressed but oriented to place and time. Neurological examination reveals weakness of the right extremities with loss of touch, position and vibratory sensations on the same side accompanied by loss of pain and temperature on the left side. What is the most likely diagnosis?

A- Anterior cord syndrome
B- Brown-Sequard syndrome
C- Central cord syndrome
D- Conus medullaris syndrome
E- Transverse myopathy

This is a typical case of unilateral spinal cord lesion known as Brown-Sequard syndrome. It is caused by trauma or tumor affecting one half of the spinal cord. It causes ipsilateral paresis or paralysis, ipsilateral loss of touch, position and vibratory sensations and contralateral loss of pain and temperature sensations.
The correct answer is B

 

Question 10. A 32-year-old recently divorced woman presents to her physician with visual disturbances that have persisted for 3 days. She reports difficulty with her vision. Upon examination, she exhibits tunnel vision and significant weakness in plantar flexion, despite being able to walk on her tiptoes without any issues. All laboratory tests and imaging studies return normal results. What is the most likely diagnosis for this patient?

A- Conversion disorder
B- Meningioma
C- Multiple sclerosis
D- Transient ischemic attack

The patient’s symptoms, such as visual disturbances (specifically tunnel vision) and weakness in plantar flexion, along with normal laboratory tests and imaging studies, suggest a functional neurological disorder rather than an organic disease. She has weakness in plantar flexion but can still walk on her tiptoes without issue, which indicates an inconsistency between the patient’s reported symptoms and actual motor abilities. This, combined with the stress of a recent divorce, points toward a psychological rather than a neurological cause.
In this case, the most likely diagnosis is conversion disorder (also known as functional neurological symptom disorder), where psychological stress manifests as neurological symptoms without any identifiable organic cause.
Thus, the correct answer is A- Conversion disorder.

 

High-yield points from this set

  • Status epilepticus: secure the airway and give oxygen first, then IV benzodiazepines.
  • Chorea, personality change and dementia in a middle-aged adult = Huntington disease.
  • Only a brain biopsy confirms glioblastoma; CT and MRI only suggest it.
  • Clear CSF with lymphocytes, normal glucose and mildly high protein = viral meningitis (enteroviruses such as echovirus).
  • Hoarseness, ipsilateral face and contralateral body sensory loss, and Horner syndrome = lateral medullary (Wallenberg) syndrome; nucleus ambiguus.
  • Wet, wobbly and wacky (incontinence, gait problems, dementia) with large ventricles = normal pressure hydrocephalus.
  • Gradual loss of recent memory with cortical atrophy = Alzheimer disease.
  • Staring with lip smacking and confusion afterward = complex (focal impaired awareness) seizure.
  • Ipsilateral weakness and loss of proprioception with contralateral loss of pain and temperature = Brown-Sequard syndrome.
  • Neurologic symptoms that do not fit anatomy, after stress, with normal tests = conversion disorder.

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