An 85-Year-Old Man with Gradual Decrease in the Level of Consciousness and Vomiting; a Photo Quiz

Abstract

An 85-year-old male was brought to emergency department (ED) from a skill nursing facility with gradual onset of lethargy and vomiting from a week ago. No clear history of head trauma and coagulopathy or using of anticoagulant agents. His past medical history included mild cognitive impairment (MCI) and diabetes mellitus which treated by oral agent. On general examination the patient looked underweight with body mass index (BMI) about 17. Neither specific stationary position of the limbs nor any spontaneous motor behavior was detected. The patient’s vital signs at admission to ED were: Blood pressure: 140/60 mmHg, pulse rate: 82 beats/minute, oxygen saturation: 95%, Respiratory Rate: 16/minute, bedside blood-glucose measurement: 268 mg/dl. The patient was afebrile. On neurologic examination in ED Glasgow coma scale (GCS) was 10/15 (eye: 3, motor: 5, verbal: 2). Mucosal membranes were dry and patient seemed to be dehydrated. Pupils were equal but had poor reaction to light. Oculocephalic maneuver, corneal reflex and gag reflex were intact. There was slight decrease in muscle tones in lower limbs. Plantar reflex in both sides seems upright. Arm and Leg dropping test showed equal motor response and deep tendon reflexes (DTR) seemed diminished in both sides. Laboratory tests included: leukocyte count: 12800/mm3 with 85% segmented neutrophils, hemoglobin: 14.1 g/dl, platelet: 268000/microliter, glucose: 234 mg/dl, sodium: 141 mEq/L, potassium: 5.1 mEq/L, Blood Urea Nitrogen (BUN): 36 mg/dl, serum creatinine: 1.3 mg/dl and international normalized ratio (INR) of 1.24. The patient underwent brain computed tomography (CT) scan without contrast materials which is showed in figure 1. What is your diagnosis?

Keywords

• Hematoma, Subdural
• Hematoma, Subdural, Chronic
• Hematoma, Subdural, Acute
• Trephining