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Subarachnoid hemorrhage evaluation after negative CT — USMLE Step 3 MCQ

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ModerateEmergency MedicineSubarachnoid hemorrhage evaluation after negative CTUSMLE Step 3

A 33-year-old man presents to the emergency department 1 hour after sudden severe headache while lifting weights. He vomited twice and says this is the worst headache of his life. Blood pressure is 168/94 mm Hg, neck stiffness is present, and neurologic examination is otherwise normal. Noncontrast head CT is normal. Which of the following is the most appropriate next step in management?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Perform lumbar puncture or CT angiography for subarachnoid hemorrhage evaluation

A thunderclap headache with meningismus remains concerning for subarachnoid hemorrhage despite an initial negative CT, particularly if timing and scanner sensitivity are uncertain. Further evaluation with LP or CT angiography is appropriate.

Reference: ACEP clinical policy on acute headache