Study guide
This chapter covers the nervous system, mental health, and the eyes, ears, nose, and throat, three areas that share a common thread: careful history-taking and a focused exam often narrow the diagnosis before any test is ordered. The material below walks through the reasoning behind commonly tested presentations. Educational content only, not medical advice.
Stroke and Seizures
A classic stroke vignette describes sudden-onset unilateral weakness, facial droop, and slurred speech, tested using tools like the Cincinnati Prehospital Stroke Scale. The history and physical task area emphasizes establishing the precise time of symptom onset, or last known well, because this determines eligibility for thrombolytic therapy. Diagnostics prioritize a non-contrast CT scan of the head immediately, primarily to exclude hemorrhage before considering intravenous alteplase or tenecteplase, which must generally be given within a defined early window from symptom onset per current guidelines, with mechanical thrombectomy an option for large-vessel occlusions within an extended window in appropriately selected patients. Hemorrhagic stroke presents similarly but is more often accompanied by severe headache, vomiting, and depressed consciousness, and thrombolysis is absolutely contraindicated. Distinguishing an ischemic stroke from a transient ischemic attack, where symptoms fully resolve within 24 hours without evidence of infarction, matters for triage and secondary prevention planning, which includes antiplatelet therapy, statin therapy, and blood pressure control. Seizures are classified as focal, involving one hemisphere with or without impaired awareness, or generalized, involving both hemispheres from onset, such as tonic-clonic seizures. A patient found unconscious, incontinent, with tongue biting and a postictal confusion period likely had a generalized tonic-clonic seizure. New-onset seizure workup includes glucose, electrolytes, and neuroimaging to exclude structural causes, while status epilepticus, a seizure lasting more than five minutes or recurrent seizures without recovery, is a medical emergency treated first-line with intravenous benzodiazepines such as lorazepam, followed by a second-line antiepileptic like fosphenytoin or levetiracetam.
Depression, Anxiety, and Substance Use
Major depressive disorder requires at least five symptoms, including depressed mood or anhedonia, present for two weeks or longer, affecting functioning, and encompassing changes in sleep, appetite, concentration, energy, and psychomotor activity, along with feelings of worthlessness or suicidal ideation. Every depression evaluation includes a direct suicide risk assessment, since asking about suicidal ideation does not increase risk and is a required competency. First-line pharmacotherapy is typically a selective serotonin reuptake inhibitor, such as sertraline, paired with psychotherapy; response is generally assessed over four to six weeks before adjusting the regimen. Generalized anxiety disorder involves excessive, difficult-to-control worry about multiple domains for six months or more, accompanied by physical symptoms like muscle tension and restlessness, and is also treated with SSRIs or serotonin-norepinephrine reuptake inhibitors as first-line therapy, since benzodiazepines carry dependence risk and are reserved for short-term or adjunctive use. Panic disorder features recurrent, unexpected panic attacks with intense physical symptoms peaking within minutes, followed by persistent worry about future attacks. Substance use disorder questions often center on withdrawal syndromes: alcohol withdrawal can progress from tremor and anxiety to seizures and, in severe cases, delirium tremens with autonomic instability and hallucinations, managed with benzodiazepines using a symptom-triggered protocol such as the CIWA-Ar scale. Opioid withdrawal, while intensely uncomfortable with symptoms like diarrhea, piloerection, and myalgias, is not life-threatening, unlike alcohol or benzodiazepine withdrawal, and can be managed with buprenorphine or supportive care.
Otitis, Sinusitis, and Vision Loss
Acute otitis media presents in a young child with ear pain, fever, and irritability, with otoscopy revealing a bulging, erythematous tympanic membrane with reduced mobility on pneumatic otoscopy. Most cases are caused by Streptococcus pneumoniae, nontypeable Haemophilus influenzae, or Moraxella catarrhalis, and first-line treatment is amoxicillin, with watchful waiting an option in select older children with mild symptoms per current pediatric guidelines. Otitis externa, or swimmer's ear, presents with pain worsened by manipulation of the tragus or pinna, and is treated with topical antibiotic drops rather than oral therapy. Acute rhinosinusitis is usually viral and self-limited, but bacterial superinfection should be suspected when symptoms persist beyond 10 days without improvement, worsen after initial improvement, or present severely with high fever and purulent discharge for several consecutive days, warranting amoxicillin-clavulanate. Vision loss vignettes require distinguishing several sight-threatening emergencies: acute angle-closure glaucoma presents with severe eye pain, headache, nausea, halos around lights, and a fixed mid-dilated pupil with elevated intraocular pressure, requiring emergent ophthalmology referral and pressure-lowering treatment. Central retinal artery occlusion causes sudden, painless, complete monocular vision loss described as a curtain coming down, representing a true ocular stroke. Retinal detachment presents with flashes of light, floaters, and a curtain-like visual field defect, while giant cell arteritis in an older adult with headache, jaw claudication, and vision loss requires immediate high-dose corticosteroids even before biopsy confirmation to prevent permanent blindness in the other eye.
Key terms
- Last known well
- — The last confirmed time a stroke patient was without symptoms; determines eligibility for thrombolytic therapy.
- Transient ischemic attack (TIA)
- — A temporary episode of neurologic dysfunction from focal ischemia that resolves within 24 hours without infarction.
- Status epilepticus
- — A seizure lasting more than five minutes, or repeated seizures without return to baseline, treated emergently with benzodiazepines.
- Anhedonia
- — Loss of interest or pleasure in previously enjoyable activities; a core diagnostic feature of major depressive disorder.
- Delirium tremens
- — A severe, life-threatening form of alcohol withdrawal marked by autonomic instability, confusion, and hallucinations.
- CIWA-Ar scale
- — A symptom-triggered assessment tool used to guide benzodiazepine dosing during alcohol withdrawal management.
- Pneumatic otoscopy
- — An otoscopic technique assessing tympanic membrane mobility, helpful in diagnosing acute otitis media and effusion.
- Acute angle-closure glaucoma
- — A sight-threatening emergency from impaired aqueous outflow causing elevated intraocular pressure, severe pain, and halos around lights.
- Central retinal artery occlusion
- — Sudden painless monocular vision loss from arterial blockage, representing an ischemic event analogous to stroke.
- Giant cell arteritis
- — A vasculitis in older adults causing headache and jaw claudication that can cause irreversible vision loss without prompt corticosteroid treatment.
Exam tips
- Time of symptom onset is the single most important data point in any stroke vignette; identify it before selecting the next diagnostic or therapeutic step.
- Always include a suicide risk assessment in depression-related vignettes; failing to address safety is a common trap in exam scenarios.
- Distinguish life-threatening alcohol and benzodiazepine withdrawal from uncomfortable but non-lethal opioid withdrawal.
- For sudden painless monocular vision loss, think central retinal artery occlusion; for painful vision loss with halos, think angle-closure glaucoma.
- In an older adult with headache and jaw claudication, treat empirically for giant cell arteritis without waiting for biopsy results to protect vision.