A 72-Year-Old Man Comes to the Emergency Department Due to Right-Sided

question 124

Multiple Choice

A 72-year-old man comes to the emergency department due to right-sided numbness and weakness.  The patient says his right side felt numb when he awoke at 5:00 AM, and he was unable to get out of bed due to right arm and leg weakness.  The patient called an ambulance and arrived at the emergency department within 45 minutes.  He was feeling well with no symptoms when he went to bed last night at 10:00 PM and does not know when his symptoms began.  The patient has never had similar symptoms and has no headache, head trauma, fever, or chills.  Medical conditions include hypertension and hyperlipidemia, but the patient is nonadherent with medical care and has not seen his primary care physician for the past several years.  He has smoked a pack of cigarettes daily for 40 years.
Temperature is 36.5 C (97.7 F) , blood pressure is 202/104 mm Hg, and pulse is 84/min and regular.  The patient is alert but has frequent word-finding difficulty.  Right facial droop is present.  Motor strength and sensation to pinprick are decreased in the right upper and lower extremities.  Babinski reflex is present on the right.  Bedside swallow assessment shows no signs of aspiration.
Noncontrast CT scan of the head reveals no evidence of subarachnoid or intracerebral hemorrhage.  Blood cell counts, serum chemistry studies, and coagulation tests are within normal limits.  Blood glucose is 120 mg/dL.  An ECG shows sinus rhythm with no acute ischemic changes, and chest radiograph is normal.
Which of the following is the most appropriate next step in management of this patient?

• A)Aspirin, clopidogrel, and an intravenous antihypertensive
• B)Aspirin and an oral antihypertensive
• C)Aspirin and evaluation for mechanical thrombectomy
• D)Intravenous antihypertensive followed by thrombolytic therapy
• E)Thrombolytic therapy only