A 69-year-old male presents to the emergency department for slurred speech and an inability to use his right arm which occurred while he was eating dinner. The patient arrived at the emergency department within one hour. A CT scan was performed of the head and did not reveal any signs of hemorrhage. The patient is given thrombolytics and is then managed on the neurology floor. Three days later, the patient is recovering and is stable. He seems depressed but is doing well with his symptoms gradually improving as compared to his initial presentation. The patient complains of neck pain that has worsened slowly over the past few days for which he is being given ibuprofen. Laboratory values are ordered and return as indicated below: Serum: Na+: 130 mEq/L K+: 3.7 mEq/L Cl-: 100 mEq/L HCO3-: 24 mEq/L Urea nitrogen: 7 mg/dL Glucose: 70 mg/dL Creatinine: 0.9 mg/dL Ca2+: 9.7 mg/dL Urine: Appearance: dark Glucose: negative WBC: 0/hpf Bacterial: none Na+: 320 mEq/L/24 hours His temperature is 99.5°F (37.5°C), pulse is 95/min, blood pressure is 129/70 mmHg, respirations are 10/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?

Continue conservative management

A 77-year-old woman is brought by ambulance to the emergency department after she developed weakness of her right arm along with a right-sided facial droop. By the time the ambulance arrived, she was having difficulty speaking. Past medical history is significant for hypertension, diabetes mellitus type II, and hyperlipidemia. She takes lisinopril, hydrochlorothiazide, metformin, and atorvastatin. On arrival to the emergency department, her vital signs are within normal limits. On physical examination, she is awake and alert but the right side of her mouth is dropping, making it difficult for her to speak clearly. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. Fingerstick glucose is 85 mg/dL. Her right upper extremity strength is 2/5 and her left upper extremity strength is 5/5. Which of the following is the best next step in management?

Obtain noncontrast CT of the brain

Start tissue plasminogen activator (tPA)

A 77-year-old man is brought to the emergency department by his wife because of headache, nausea, and vomiting for 24 hours. His wife says that over the past 2 weeks, he has been more irritable and has had trouble remembering to do routine errands. Two weeks ago, he fell during a skiing accident but did not lose consciousness. He has coronary artery disease and hypertension. He has smoked one pack of cigarettes daily for 50 years. He has had 2 glasses of wine daily since his retirement 10 years ago. Current medications include atenolol, enalapril, furosemide, atorvastatin, and aspirin. He appears acutely ill. He is oriented to person but not to place or time. His temperature is 37°C (98.6°F), pulse is 99/min, respirations are 16/min, and blood pressure is 160/90 mm Hg. During the examination, he is uncooperative and unable to answer questions. Deep tendon reflexes are 4+ on the left and 2+ on the right. Babinski's sign is present on the left. There is mild weakness of the left iliopsoas and hamstring muscles. A CT scan of the head without contrast shows a high-density, 15-mm crescentic collection across the right hemispheric convexity. Which of the following is the most appropriate next step in the management of this patient?

Recombinant tissue plasminogen activator administration

Obtain an Electroencephalography

An 8-month-old boy is brought to the emergency department by his mother. She is concerned that her son has had intermittent periods of severe abdominal pain over the past several days that has been associated with emesis and "currant jelly" stool. Of note, the family lives in a rural part of the state, requiring a 2 hour drive to the nearest hospital. He currently appears to be in significant pain and has vomited twice in the past hour. On physical examination, a sausage-shaped mass is noted on palpation of the right upper quadrant of the abdomen. Ultrasound of the abdomen was consistent with a diagnosis of intussusception. An air-contrast barium enema was performed, which confirmed the diagnosis and also successfully reduced the intussusception. Which of the following is the next best step in the management of this patient?

Admit to hospital for 24 hour observation for complications and/or recurrence

Keep patient NPO and initiate work-up to identify lead-point

Pursue urgent surgical reduction with resection of necrotic segments of bowel

Repeat barium enema q6 hrs to monitor for recurrence

Discharge to home with follow-up in 3 weeks in an outpatient pediatric gastroenterology clinic

Management of stroke complications for USMLE Step 2 CK: High-Yield Management Lessons

Neurological Issues - Brain Under Siege

CT scan: Malignant MCA stroke progression

Cerebral Edema & ↑ Intracranial Pressure (ICP)
- Pathophysiology: Cytotoxic edema peaks 3-5 days post-infarct, leading to mass effect.
- Clinical Signs: Deteriorating consciousness, new focal deficits, Cushing's triad.
- Management: Follows a tiered approach to lower ICP and improve cerebral perfusion.
Seizures
- Incidence: ~5% of patients; can be early (<1 week) or late (>1 week).
- Acute Management: Benzodiazepines (e.g., Lorazepam).
- Prevention: Prophylaxis is not routine. Start an AED (e.g., Levetiracetam) after a first seizure.
Hemorrhagic Transformation
- Ischemic tissue converts into a hemorrhage.
- Major risk factors: Large infarct size, thrombolysis (tPA), anticoagulation.
- Action: Immediately stop offending agents; urgent neurosurgical evaluation.

⭐ Malignant MCA Syndrome: A devastating complication in large MCA strokes with massive edema. Decompressive hemicraniectomy within 48 hours of stroke onset is life-saving and improves outcomes in patients <60 years.

Systemic Crises - Body-Wide Breakdown

Hypertension: A critical balancing act.
- Ischemic Stroke: Allow "permissive hypertension" (up to 220/120 mmHg) to maintain cerebral perfusion. If thrombolysis (tPA) was administered, strictly maintain BP < 185/110 mmHg to prevent hemorrhagic conversion.
- Hemorrhagic Stroke: Aggressively lower systolic BP, with a common target of < 140 mmHg.
Hyperglycemia: Stress-induced state that worsens neurologic outcomes. Target glucose range is 140-180 mg/dL using insulin; avoid hypoglycemia.
Fever: Increases metabolic demand and exacerbates neuronal injury. Treat promptly with antipyretics while investigating underlying infections (e.g., aspiration pneumonia, UTI).
VTE Prophylaxis: For all immobile patients.

⭐ Post-stroke cardiac monitoring is vital. Strokes involving the insular cortex are particularly associated with dangerous arrhythmias (like AFib) and even Takotsubo cardiomyopathy.

Rehabilitation Phase - Rebuilding Life

Goal: Maximize functional independence and quality of life through a multidisciplinary team (PT, OT, SLP).
Physical Therapy (PT):
- Focuses on mobility, strength, balance, and gait training.
- Prevents complications like joint contractures and deep vein thrombosis (DVT).
Occupational Therapy (OT):
- Aids in regaining Activities of Daily Living (ADLs) like dressing, bathing, and eating.
- Involves adaptive strategies and equipment.
Speech-Language Pathology (SLP):
- Addresses aphasia (language deficits), dysarthria (slurred speech), and dysphagia (swallowing difficulty).
- Crucial for preventing aspiration pneumonia.
Spasticity Management: Treat with physical modalities first, then consider baclofen, tizanidine, or botulinum toxin for focal spasticity.
Post-Stroke Depression: Common; screen and treat with SSRIs to improve participation and outcomes.

Stroke patient in physical therapy rehabilitation

⭐ Constraint-Induced Movement Therapy (CIMT): An OT technique involving restraining the unaffected limb to force the use of the weaker, affected limb, promoting neuroplasticity and functional recovery.

High-Yield Points - ⚡ Biggest Takeaways

Cerebral edema is a peak cause of mortality 3-5 days post-stroke; manage with hyperosmolar therapy (mannitol, hypertonic saline).

Suspect hemorrhagic transformation with neurologic worsening after tPA; get an immediate non-contrast CT.

Prophylactic anticonvulsants are not indicated; treat seizures only when they occur.

Prevent DVT/PE with early mobilization and subcutaneous heparin/LMWH once hemorrhage is ruled out.

Keep patients NPO until a formal swallowing study clears them to prevent aspiration pneumonia.

Post-stroke depression is common; screen and treat with SSRIs.

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