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A 73-Year-Old Man With a Mild Headache


A 73-year-old man presents to the emergency department with a 3-day history of mild headache and somnolence. His wife notes that he has periods when he seems "off," that he has been napping frequently, and that he has had a poor appetite. They deny any history of trauma, seizures, or focal neurologic deficits. Symptomatic review of the cardiopulmonary, gastrointestinal, and genitourinary systems is unremarkable. The patient drinks 5-6 ounces of hard liquor per day, but he does not smoke or use illicit drugs. He has not travelled recently, and there have been no changes in his daily routine. He takes a baby aspirin daily for unknown reasons but no other medications. He denies allergies or any other medical conditions. He has never had major surgery.

On physical examination, the patient appears well. Despite the fact that the patient is slightly vague and tangential in answering questions, his Glasgow Coma Scale score is 15. His blood pressure is 180/90 mm Hg, and his heart rate is 80 bpm and regular. The respiratory rate is 16 breaths/min. He is afebrile, with a recorded temperature of 98.1°F (36.7°C). His heart sounds are normal, and he is euvolemic. The lungs are clear on auscultation, and his abdomen is soft, nontender, and without any masses. A detailed cranial nerve examination demonstrates no abnormalities, and funduscopy is normal. The patient's neck is supple, and his cerebellar function tests are normal. He lacks any pronator drift and has a negative Romberg sign. Motor and sensory examination of all 4 limbs is normal; however, he is slightly hyperreflexic at his biceps and patellar tendons.

A workup of the patient's altered mental status is initiated. A complete blood cell count, chest x-ray, liver enzymes examination, thyroid function test, electrocardiogram, and urinalysis are all normal. Electrolytes are normal except for a sodium of 129 mEq/L (12 mmol/L). Computed tomography (CT) of the head is performed (see Figure 1). The brain is asymmetric, and a suspected lesion is noted on the right side. Signs of increased intracranial pressure (ICP), including effacement of the right-sided ventricles, obliteration of the right-sided sulci, and midline shift, are apparent. The brain parenchyma on the left is noted to be atrophic, with prominent sulci. The right-sided lesion is hypodense-to-isodense compared with the surrounding parenchyma.

What is the diagnosis?

Hint: Consider the density of the right-sided lesion seen on the CT scan.
Epidural hematoma
Acute subdural hematoma
Subacute/chronic subdural hematoma
Intracranial tumor
Subarachnoid hemorrhage

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1.  IiuXsVYaZKRwGOqk  (04/08/2014 14:51)
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8.  ABLqtYCgvLHRWcHHf  (03/08/2014 14:21)
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10.  SMGdtrDzyf  (03/08/2014 14:21)
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