Vascular Disease USMLE Step 1 Practice Question
A 58-year-old woman with a 10-year history of hypertension presents to the emergency department with acute-onset right-sided hemiparesis and expressive aphasia. Symptoms began 4 hours ago while she was at home. Vital signs: BP 168/94 mmHg, HR 88/min, RR 16/min, temp 37.2°C, SpO2 98% on room air. Non-contrast CT head is unremarkable with no evidence of hemorrhage or acute ischemic changes. Labs show INR 0.98, platelet count 245,000/μL, and glucose 98 mg/dL. Carotid duplex ultrasound demonstrates severe left internal carotid artery (ICA) stenosis (>70%) with irregular, ulcerated plaque. The patient is not on anticoagulation therapy. Which of the following is the most appropriate next step in management?
Answer choices
- AAdminister intravenous alteplase and proceed to urgent carotid endarterectomy within 24 hoursCorrect answer
- BInitiate aspirin therapy and defer carotid intervention pending repeat imaging in 4 weeks
- CStart unfractionated heparin anticoagulation and schedule carotid endarterectomy within 2 weeks
- DPerform urgent carotid angiography followed by endovascular stent placement
- EAdminister intravenous alteplase alone without carotid intervention at this time
- FInitiate dual antiplatelet therapy and observe with serial ultrasound imaging
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