A patient on warfarin with a complex medical history suddenly begins slurring his words during the appointment and is found to have markedly elevated blood pressure. What is the most likely cause?

Correct answer: B. Cerebrovascular accident (stroke)

• A. Hyperventilation causes perioral and digital paraesthesia, carpopedal spasm and light-headedness from respiratory alkalosis — not focal speech loss with hypertension.
• B. CORRECT. Sudden onset of a FOCAL NEUROLOGICAL deficit — slurred speech (dysarthria), facial droop, unilateral weakness — with markedly elevated blood pressure is a CEREBROVASCULAR ACCIDENT until proven otherwise. Warfarin therapy raises the possibility of haemorrhagic stroke in particular. Activate EMS immediately, note the time of symptom onset (this drives thrombolysis eligibility), position the patient with the head slightly elevated, give oxygen, monitor vitals, and give nothing by mouth.
• C. Myocardial infarction presents with crushing substernal chest pain radiating to the arm or jaw, dyspnoea and diaphoresis. Isolated slurred speech is not its presentation.
• D. Vasovagal syncope presents with pallor, sweating, nausea, bradycardia and HYPOtension followed by brief loss of consciousness with rapid recovery — the blood pressure picture is the opposite of what is described.

Note: Use FAST: Face droop, Arm weakness, Speech difficulty, Time to call EMS. Time of onset is the single most important piece of information to hand over.