What is the diagnosis and treatment for a diabetic adult patient with significantly elevated blood pressure (hypertension), presenting with transient symptoms of slurred speech and right-sided weakness, now resolved, with no current medications for diabetes or hypertension, normal oxygen saturation (O2 sat), and normal laboratory results?

Diagnosis: Transient Ischemic Attack (TIA) with Hypertensive Emergency

This patient experienced a transient ischemic attack (TIA) in the setting of severe uncontrolled hypertension (210/110 mmHg), and requires immediate blood pressure reduction followed by urgent initiation of antihypertensive therapy, antiplatelet therapy, and comprehensive stroke prevention measures. 1

Immediate Management of Blood Pressure

For this patient without ongoing neurological symptoms, blood pressure should be reduced by no more than 25% within the first hour, then cautiously to 160/100 mmHg within the next 2-6 hours, and then to normal during the following 24-48 hours. 1

• The patient does not have a hypertensive emergency with ongoing end-organ damage (symptoms have resolved), but the BP of 210/110 mmHg represents severe hypertension requiring urgent but controlled reduction 1
• Avoid rapid BP reduction as this can compromise cerebral perfusion and worsen ischemic injury 1
• Oral antihypertensive therapy is appropriate since this is not an acute stroke in evolution 1

Antiplatelet Therapy

Initiate aspirin 325 mg immediately (or clopidogrel 75 mg if aspirin-intolerant) to reduce risk of recurrent stroke. 1

• Adults who experience a TIA should be restarted on antihypertensive treatment after the first few days to reduce risk of recurrent stroke 1
• The annual risk of stroke after TIA is approximately 4%, with substantially higher mortality if recurrent stroke occurs 1

Long-Term Antihypertensive Management

This patient requires combination antihypertensive therapy with an ACE inhibitor (or ARB) plus a thiazide diuretic as first-line treatment, with a target blood pressure of <130/80 mmHg. 1

Specific Medication Recommendations:

• Start an ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB if ACE inhibitor not tolerated, as these are preferred first-line agents for diabetic patients with hypertension 1
• Add a thiazide diuretic (e.g., chlorthalidone 12.5-25 mg daily), as combination therapy is generally required to achieve BP targets in diabetic patients 1
• Multiple-drug therapy is typically necessary to achieve target BP <130/80 mmHg in diabetic patients 1

Monitoring Requirements:

• Check serum creatinine, eGFR, and potassium within 7-14 days after initiating ACE inhibitor/ARB and diuretic, then every 6 months if stable 1, 2
• This is critical to avoid acute kidney injury and hyperkalemia, which are common pitfalls with these medications 2

Diabetes Management

Initiate metformin therapy immediately (starting at 500 mg daily, titrating to 1000 mg twice daily as tolerated) for glycemic control, as this patient has diabetes but is on no medications. 3

• Check HbA1c to establish baseline glycemic control and guide therapy 2, 3
• Target HbA1c <7.5% for this 61-year-old to balance glycemic control against hypoglycemia risk 2
• Fasting plasma glucose should be monitored regularly 2

Additional Stroke Prevention Measures

Obtain urgent carotid duplex ultrasound to evaluate for carotid stenosis, as this could be the source of the TIA and may require revascularization. 1

Order brain MRI with diffusion-weighted imaging to document any acute ischemic changes and evaluate for other vascular lesions. 4

Initiate statin therapy (e.g., atorvastatin 40-80 mg daily) as this diabetic patient over age 40 with cardiovascular disease (TIA) requires high-intensity statin therapy regardless of baseline lipid levels. 1, 2

• Target LDL-C <70 mg/dL given overt cardiovascular disease 1
• Check fasting lipid profile to establish baseline 1, 2

Critical Screening and Monitoring

Schedule comprehensive diabetic complication screening within 1-2 weeks: 2

• Dilated eye examination for diabetic retinopathy 2
• Urine albumin-to-creatinine ratio (UACR) for diabetic nephropathy 2
• Foot examination with monofilament testing for peripheral neuropathy 2
• ECG to screen for silent coronary artery disease 2

Common Pitfalls to Avoid

• Do not lower BP too rapidly in the acute setting, as this can worsen cerebral ischemia by reducing perfusion pressure 1
• Do not delay antihypertensive therapy beyond the first few days after TIA, as this substantially increases recurrent stroke risk 1
• Do not neglect renal function monitoring when starting ACE inhibitors/ARBs and diuretics, as acute kidney injury and hyperkalemia are serious complications 1, 2
• Do not overlook carotid imaging, as significant stenosis may require revascularization to prevent recurrent stroke 1
• Do not use monotherapy for hypertension in diabetic patients, as combination therapy is almost always required to achieve target BP <130/80 mmHg 1