20 Feb Case Study Assignment 1: 92‑Year‑Old African American Male with Slurred Speech and Hypertension

1. Introduction
Patient Profile:

Age: 92 years old.

Ethnicity: African American.

Presenting Complaint: Slurred speech.

Brought by: Daughter to Emergency Department.

Vital Signs: Blood pressure 210/100 mmHg.

Clinical Significance:

Slurred speech + severe hypertension suggests possible neurological emergency (stroke, transient ischemic attack).

Advanced age and ethnicity increase risk factors for cerebrovascular disease.

2. Initial Assessment
Airway, Breathing, Circulation (ABCs): Ensure stability.

Neurological Status:

Glasgow Coma Scale (GCS).

Cranial nerve exam (facial droop, tongue deviation).

Motor and sensory deficits.

Vital Signs:

Severe hypertension (210/100) → hypertensive crisis.

Monitor heart rate, oxygen saturation, temperature.

History Gathering:

Onset of symptoms (sudden vs gradual).

Past medical history: hypertension, diabetes, atrial fibrillation, prior strokes.

Medications: antihypertensives, anticoagulants.

Social history: smoking, alcohol, diet.

Family history: cardiovascular disease.

3. Differential Diagnosis
Ischemic Stroke:

Slurred speech (dysarthria) is a common symptom.

Risk factors: age, hypertension, African American ethnicity.

Hemorrhagic Stroke:

Severe hypertension can cause intracerebral hemorrhage.

Symptoms: headache, vomiting, altered consciousness.

Transient Ischemic Attack (TIA):

Temporary neurological deficits, often resolve within 24 hours.

Hypertensive Encephalopathy:

Severe hypertension → confusion, neurological deficits.

Other Causes:

Hypoglycemia, electrolyte imbalance, infection (sepsis), medication side effects.

4. Diagnostic Workup
Laboratory Tests:

CBC, electrolytes, renal function.

Blood glucose (rule out hypoglycemia).

Coagulation profile.

Imaging:

CT scan of the head (rule out hemorrhage).

MRI brain (detect ischemic changes).

Cardiac Evaluation:

ECG (atrial fibrillation, arrhythmias).

Echocardiogram (cardiac source of emboli).

Other:

Carotid Doppler (stenosis).

Chest X‑ray (cardiomegaly, pulmonary edema).

5. Pathophysiology
Hypertension:

Chronic high BP damages vascular endothelium.

Promotes atherosclerosis and vessel rupture.

Stroke:

Ischemic: clot blocks cerebral artery → reduced blood flow.

Hemorrhagic: vessel rupture → bleeding into brain tissue.

Neurological Deficits:

Slurred speech due to involvement of motor speech areas (Broca’s area, cranial nerves).

Possible hemiparesis, facial droop.

6. Management in Emergency Department
Immediate Priorities:

Stabilize airway, breathing, circulation.

Monitor neurological status.

Blood Pressure Control:

Hypertensive emergency: gradual reduction with IV antihypertensives (labetalol, nicardipine).

Avoid rapid BP drop (risk of worsening ischemia).

Stroke Protocol:

If ischemic stroke: evaluate for thrombolysis (tPA) within 3–4.5 hours of onset.

If hemorrhagic stroke: neurosurgical consultation.

Supportive Care:

Oxygen, IV fluids, glucose control.

Prevent complications (aspiration, DVT).

7. Long‑Term Management
Secondary Prevention:

Antihypertensives (ACE inhibitors, diuretics, calcium channel blockers).

Antiplatelets (aspirin, clopidogrel) for ischemic stroke.

Statins for cholesterol control.

Lifestyle Modifications:

Low‑sodium diet, exercise, smoking cessation.

Rehabilitation:

Speech therapy, physical therapy, occupational therapy.

Monitoring:

Regular BP checks.

Follow‑up with neurology and cardiology.

8. Special Considerations in Elderly African American Patients
Age:

Increased vulnerability to vascular disease.

Polypharmacy risks.

Ethnicity:

Higher prevalence of hypertension and stroke in African Americans.

Genetic and socioeconomic factors contribute.

Cultural Competence:

Respect cultural beliefs and family involvement.

Address health disparities and access to care.

9. Ethical and Legal Considerations
Informed Consent:

Involve patient and daughter in decision‑making.

End‑of‑Life Care:

Discuss advanced directives, code status.

Equity in Care:

Ensure unbiased treatment regardless of age or ethnicity.

10. Summary
A 92‑year‑old African American male presents with slurred speech and severe hypertension.

Differential diagnoses include ischemic stroke, hemorrhagic stroke, TIA, hypertensive encephalopathy.

Immediate management involves stabilization, BP control, imaging, and stroke protocol.

Long‑term care requires secondary prevention, lifestyle changes, rehabilitation, and culturally competent care.

This case highlights the importance of rapid recognition, evidence‑based management, and holistic patient care in elderly populations.

📝 Quiz (15 Questions)
Multiple Choice – Select the best answer.

What is the patient’s presenting symptom? a) Chest pain b) Slurred speech c) Shortness of breath d) Abdominal pain

What is the patient’s blood pressure on arrival? a) 120/80 b) 140/90 c) 210/100 d) 180/95

Slurred speech in stroke is due to involvement of: a) Broca’s area and cranial nerves b) Cerebellum only c) Spinal cord d) Occipital lobe

Which condition is most likely given age, ethnicity, and symptoms? a) Ischemic stroke b) Asthma c) Appendicitis d) Migraine

Which imaging is first‑line in suspected stroke? a) CT scan of the head b) Chest X‑ray c) Abdominal ultrasound d) MRI spine

Which lab test rules out hypoglycemia? a) CBC b) Blood glucose c) Coagulation profile d) Electrolytes

Which antihypertensive is commonly used in hypertensive emergencies? a) Labetalol b) Aspirin c) Statins d) Insulin

What is the time window for tPA in ischemic stroke? a) 1 hour b) 3–4.5 hours c) 12 hours d) 24 hours

Which symptom suggests hemorrhagic stroke? a) Headache and vomiting b) Constipation c) Weight gain d) Polyuria

Which lifestyle change is recommended for hypertension? a) High‑sodium diet b) Smoking cessation c) Sedentary lifestyle d) Increased alcohol intake

Which therapy helps with slurred speech recovery? a) Speech therapy b) Chemotherapy c) Dialysis d) Radiation

Which ethnic group has higher stroke prevalence? a) African Americans b) Asians c) Europeans d) Native Americans

Which ethical issue is important in elderly care? a) Informed consent and advanced directives b) Ignoring family input c) Withholding information d) Avoiding cultural competence

Which medication prevents recurrent ischemic stroke? a) Aspirin b) Insulin c) Levothyroxine d) Antibiotics

Why is rapid recognition of stroke critical? a) Prevents long‑term neurological damage b) Reduces hospital costs only c) Eliminates need for imaging d) Avoids rehabilitation