A 61-year-old female presents with a severe headache and right arm weakness. She has hypertension and is on HCTZ and Glucophage. Her BP is 178/102, respirations 18, and glucose is 64 mg/dL. What should you suspect?

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A sudden onset focal neurological deficit in an older patient with vascular risk factors is most suggestive of a cerebrovascular accident. The right arm weakness points to a lesion in the brain that controls motor function contralaterally, and the accompanying severe headache raises concern for a vascular event rather than a benign metabolic issue. While glucose is 64 mg/dL, which is mildly low, this level alone doesn’t typically produce a persistent focal deficit like this—and metformin infrequently causes hypoglycemia. Migraine with aura or aneurysm rupture could present with headache, but the unilateral limb weakness in the context of hypertension makes stroke the most likely diagnosis. Initiate stroke protocol with rapid imaging and transport to a stroke center.