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(Drug information on metoprolol), digoxin(Drug information on digoxin), and warfarin(Drug information on 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.