A 67-Year-Old Man Is Brought to the Emergency Department Due

question 209

Multiple Choice

A 67-year-old man is brought to the emergency department due to right-sided weakness, numbness, and slurred speech.  The patient was in his usual state of health last night but awoke this morning with these symptoms.  He has a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, and peripheral arterial disease.  The patient does not drink alcohol regularly but has a 45-pack-year history.  Physical examination shows an awake and alert patient with right-sided weakness, hemisensory loss, homonymous hemianopsia, and aphasia.  CT scan of the head reveals a large left hemispheric infarction due to an occluded middle cerebral artery.  The patient is hospitalized but is not treated with fibrinolytic therapy or mechanical thrombectomy due to ineligibility.  Forty-eight hours later, he becomes obtunded.  Temperature is 38.3 C (100.9 F) , blood pressure is 154/86 mm Hg, and pulse is 64/min.  Physical examination now shows complete right hemiplegia and deviation of the eyes to the left.  Which of the following is the best next step in management of this patient?

• A)Blood cultures and empiric antibiotics
• B)Intravenous hypertonic saline and observation
• C)Intravenous mannitol and observation
• D)MRI of the head
• E)Repeat CT scan of the head

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