What is the appropriate assessment and management plan for an adult with hypertension, type‑2 diabetes, chronic kidney disease (CKD), benign prostatic hyperplasia (BPH), prior atherothrombotic infarct in the left‑main coronary artery territory, now presenting with a 10/10 frontal headache, mild right‑sided cerebellar signs, NIHSS (National Institutes of Health Stroke Scale) 4, and functional dependence?

Assessment and Plan

Assessment

This patient presents with acute stroke syndrome requiring emergent neuroimaging and likely acute stroke intervention. The two-week history of left-sided weakness, dysarthria, and now worsening frontal headache with NIHSS 4 and right cerebellar signs (dysmetria, dysdiadochokinesia) indicates either a new posterior circulation stroke or progression of an existing infarct. 1, 2

Key Clinical Features:

• Stroke presentation: Left-sided weakness with dysarthria two weeks ago, now with right cerebellar signs and NIHSS 4 suggests either bilateral involvement or a new posterior circulation event 1
• Severe headache: New-onset 10/10 frontal headache is concerning for hemorrhagic transformation, posterior circulation stroke, or increased intracranial pressure 1
• Vascular risk factors: Uncontrolled hypertension (no BP monitoring), uncontrolled diabetes (no glucose monitoring), CKD, prior atherothrombotic stroke, and coronary artery disease place this patient at extremely high cardiovascular risk 3
• Medication non-adherence: Despite being on appropriate secondary prevention medications (losartan, simvastatin, dapagliflozin), lack of BP and glucose monitoring suggests poor disease control 3

Differential Diagnosis:

1. Acute ischemic stroke (posterior circulation territory)
2. Hemorrhagic transformation of prior infarct
3. Intracranial hemorrhage (given uncontrolled hypertension)
4. Posterior reversible encephalopathy syndrome (PRES) from hypertensive emergency
5. Cerebellar mass lesion (less likely given acute presentation)

Plan

Immediate Management (Emergency Department/Stroke Unit):

Obtain emergent non-contrast head CT followed by CT angiography of head and neck to rule out hemorrhage and identify large vessel occlusion. If hemorrhage is excluded and patient is within therapeutic window, proceed with acute stroke protocol. 1, 2

• Vital signs: Measure blood pressure immediately; if ≥185/110 mmHg, initiate controlled BP reduction per acute stroke protocol before considering thrombolysis 3
• Laboratory work: Complete blood count, comprehensive metabolic panel (including creatinine/eGFR given CKD), coagulation studies, troponin, HbA1c, lipid panel 3
• ECG: Rule out atrial fibrillation or acute coronary syndrome 3
• Neurology consultation: Immediate stroke team evaluation for potential thrombolysis or thrombectomy if within appropriate time window 1

Blood Pressure Management:

Target BP <130/80 mmHg after acute stroke period, but avoid aggressive lowering in the hyperacute phase unless BP >185/110 mmHg and thrombolysis is planned. 3

Current Regimen Assessment:

• Losartan 50 mg twice daily is appropriate for this patient with diabetes, CKD, and prior stroke, but the dose may be inadequate 3
• Add amlodipine 5-10 mg daily as second-line agent to achieve BP target, as combination therapy with ACE inhibitor/ARB plus calcium channel blocker is recommended for patients with stage 2 hypertension and high cardiovascular risk 3, 2
• Consider adding chlorthalidone 12.5-25 mg daily if BP remains uncontrolled on dual therapy, as triple therapy (RAS blocker + CCB + thiazide) is indicated for resistant hypertension 3, 2
• Establish home BP monitoring with target readings documented at least twice daily 3, 1

Critical pitfall: Do not combine losartan with an ACE inhibitor or aliskiren, as dual RAS blockade increases cardiovascular and renal risk without benefit. 3

Diabetes Management:

Continue dapagliflozin 10 mg daily, as SGLT2 inhibitors reduce cardiovascular events and slow CKD progression in patients with type 2 diabetes and established cardiovascular disease. 3

• Initiate home glucose monitoring: Fasting and pre-meal glucose checks with target HbA1c <7% 3
• Consider adding GLP-1 receptor agonist (e.g., semaglutide, dulaglutide) if HbA1c remains elevated, as these agents provide additional cardiovascular and renal protection in high-risk patients 3

Chronic Kidney Disease Management:

Optimize RAS blockade with losartan for renoprotection, monitoring serum creatinine and potassium 2-4 weeks after any dose adjustment. 3

• Acceptable creatinine increase: Up to 30% elevation in serum creatinine after initiating or increasing losartan is acceptable and indicates appropriate reduction in intraglomerular pressure 3
• Monitor for hyperkalemia: Check potassium 2-4 weeks after medication changes, especially given concurrent use of losartan and potential need for additional agents 3
• Continue sodium bicarbonate 650 mg three times daily for metabolic acidosis management in CKD 3

Lipid Management:

Continue simvastatin 40 mg at dinner for secondary stroke prevention. Consider switching to high-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg) if LDL remains >70 mg/dL, as patients with prior stroke and diabetes require aggressive lipid lowering. 3

Antiplatelet Therapy:

Initiate aspirin 81-325 mg daily (if not already prescribed) for secondary stroke prevention, unless contraindicated by hemorrhage on imaging. Consider dual antiplatelet therapy (aspirin + clopidogrel) for 21-90 days if acute ischemic stroke is confirmed. 3, 1

Benign Prostatic Hyperplasia:

Continue tamsulosin 200 mcg twice daily. Note that alpha-1 blockers may cause orthostatic hypotension, particularly in elderly patients with multiple antihypertensive medications; monitor for falls. 3

Functional Status and Rehabilitation:

Arrange physical therapy, occupational therapy, and speech therapy evaluation given baseline functional dependence and current neurological deficits. Early mobilization and rehabilitation are critical for stroke recovery. 1

Follow-Up Schedule:

• Neurology follow-up: Within 1-2 weeks post-discharge for stroke management and secondary prevention optimization 1
• Primary care follow-up: Within 1 month to reassess BP control, review home BP log, and adjust medications as needed 3, 2
• Nephrology referral: For CKD management and optimization of renoprotective therapy 3
• Monthly BP checks: Until target <130/80 mmHg is consistently achieved 3, 2

Patient and Caregiver Education:

• Stroke warning signs: Teach FAST (Face drooping, Arm weakness, Speech difficulty, Time to call 911) and emphasize immediate emergency department presentation for any new symptoms 1
• Medication adherence: Provide written medication schedule and emphasize importance of daily compliance 3
• Home monitoring: Train patient/caregiver on proper BP and glucose measurement techniques with documentation 3, 1
• Lifestyle modifications: Sodium restriction (<2 g/day), DASH diet, weight management if overweight, and regular physical activity as tolerated 3, 1

Critical pitfall: Do not delay neuroimaging or stroke evaluation while optimizing chronic disease management. The acute neurological presentation takes absolute priority and requires emergent assessment regardless of chronic comorbidities. 1, 2