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Chronic Subdural Hematoma: "Symptoms Are Indefinite, and the Diagnosis Cannot Be Made With Certainty"

Chronic Subdural Hematoma: "Symptoms Are Indefinite, and the Diagnosis Cannot Be Made With Certainty"

THE CASE:
A 69-year-old retired accountant presents with a 2-month history of daily headaches. The pain is moderate, constant,
global, pressure-like, and occasionally pulsating; it is sometimes exacerbated when the patient lies down. He denies nausea
or vomiting, ocular symptoms, weakness, or sensitivity to light. His wife reports that years ago he experienced throbbing
headaches regularly.

About 3 or 4 months ago, the patient fell and hit his head on the nightstand. He did not lose consciousness and,
because he felt well, did not seek medical attention.

He occasionally feels lightheaded and has had difficulty remaining asleep at night. His wife has observed increased
daytime sleepiness, a major and sudden decline in his short-term memory, and personality changes. She no longer lets
him drive because on several occasions he became confused and was unable to make appropriate decisions.

The patient has hypertension and atrial fibrillation and is taking metoprolol, digoxin, and warfarin. He is a nonsmoker
and has consumed 3 to 5 alcoholic drinks per week for years. Until recently, he was very active.

This slightly lethargic man offers delayed and sometimes inappropriate responses to questions and has no interest in
his environment. He has short-term memory lapses. Blood pressure is normal; heart rate is regular; no evidence of
carotid bruits. Cranial nerves are normal and there is no papillary edema. Neck is supple. Deep tendon reflexes and
cerebellar examination are normal except for a slightly widened gait. There are no pathologic reflexes.

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