A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 62-year-old man is brought to the emergency department 40 minutes after his wife noticed during breakfast that the left side of his face was drooping. He had difficulty putting on his shirt and shoes before coming to the hospital. He has type 2 diabetes mellitus, hypertension, and hypercholesterolemia. His current medications include metformin, enalapril, and atorvastatin. He has smoked one pack of cigarettes daily for 35 years. He drinks one glass of wine daily. He is alert and oriented to time, place and person. His temperature is 37°C (98.6°F), pulse is 99/min and blood pressure is 170/100 mm Hg. Examination shows equal and reactive pupils. There is drooping of the left side of the face. Muscle strength is decreased in the left upper and lower extremities. Plantar reflex shows an extensor response on the left side. Speech is dysarthric. There is a bruit on the right side of the neck. Fundoscopy shows no abnormalities. A complete blood count, coagulation profile, and serum concentrations of glucose and electrolytes are within the reference range. Which of the following is the most appropriate next step in management?
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A
MRI of the brainIncorrect. MRI is more sensitive for acute ischemia but is slower and less accessible than CT in an acute stroke; CT comes first to exclude hemorrhage.
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B
Lumbar punctureIncorrect. Lumbar puncture is for SAH when CT is negative and suspicion remains — it is not the first test in a focal deficit suggestive of stroke.
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C
Duplex ultrasonography of the neckIncorrect. Carotid duplex is part of secondary workup to identify embolic source after stroke is confirmed and characterized — not the immediate first step.
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D
CT scan of the headCorrect. Non-contrast CT distinguishes ischemic from hemorrhagic stroke quickly, enabling time-sensitive thrombolytic decisions.
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E
Immediate IV tPA administrationIncorrect. Thrombolysis is given only AFTER non-contrast CT excludes hemorrhage; administering tPA before imaging risks catastrophic bleeding into an undiagnosed hemorrhagic stroke.
↑ Tap an answer to reveal the reasoning
Answer: D. An acute focal neurologic deficit (left face droop, left hemiparesis, left Babinski, dysarthria) in a 62-year-old hypertensive diabetic smoker is an acute stroke until proven otherwise. The single most important next step is a NON-CONTRAST CT scan of the head — this is fast (minutes), widely available, and answers the critical question: is this an ISCHEMIC or HEMORRHAGIC stroke?
The distinction matters because the management diverges sharply. Ischemic stroke within the thrombolytic window (≤4.5 hours from onset) is treated with IV tPA, which is contraindicated in hemorrhagic stroke (would cause catastrophic bleeding). At 40 minutes of symptoms, this patient is well within the tPA window.
MRI is more sensitive for early ischemia but is slower and less available in the acute setting; it's typically obtained later. Duplex ultrasonography of the carotid (which would identify the carotid stenosis suggested by his bruit) is part of the secondary workup, not the acute decision. Lumbar puncture is for subarachnoid hemorrhage when CT is non-diagnostic and clinical suspicion is high — not the first step in a typical focal deficit. The mnemonic: time is brain — non-contrast CT first to exclude hemorrhage, then thrombolysis if criteria met.
**Why each option:**
**A.** MRI is more sensitive for acute ischemia but is slower and less accessible than CT in an acute stroke; CT comes first to exclude hemorrhage.
**B.** Lumbar puncture is for SAH when CT is negative and suspicion remains — it is not the first test in a focal deficit suggestive of stroke.
**C.** Carotid duplex is part of secondary workup to identify embolic source after stroke is confirmed and characterized — not the immediate first step.
**D.** Correct. Non-contrast CT distinguishes ischemic from hemorrhagic stroke quickly, enabling time-sensitive thrombolytic decisions.