USMLE Step 2 CK Question Bank

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NeurologyHard

A 48-year-old man presents to the ED with a sudden-onset headache he describes as "the worst of my life," peaking within seconds while lifting at the gym. He has no prior headache history. BP is 172/98 mmHg, GCS is 15, neck is supple. Non-contrast CT of the head obtained 5 hours after onset shows no hemorrhage. Which of the following is the most appropriate next step?

AMRI brain with gadoliniumYour answer
BLumbar punctureCorrect
CAdminister sumatriptan and arrange neurology follow-up
DDischarge with tension headache diagnosis and ibuprofen
ERepeat non-contrast CT head in 24 hours
Why A is the trap: MRI is more sensitive than CT for most brain pathology — so it feels like the logical upgrade. But for subarachnoid hemorrhage, sensitivity of CT drops after the first few hours as blood becomes isodense. The missing blood doesn't show up better on MRI; it shows up in the CSF as xanthochromia. No imaging catches that. Anchoring on "get better imaging" is exactly what NBME is testing here.
Strategy: Thunderclap headache + negative CT ≠ ruled out. LP for xanthochromia is mandatory before you can exclude SAH. The reflex to "get better imaging" is the trap — this diagnosis requires a body fluid analysis, not a better picture.

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