A 65-year-old Hispanic man presents to the emergency department via EMS after an unwitnessed fall from a presumed standing height, as he was found lying on the ground near his vehicle. The patient was unable to provide a thorough history, and it was unclear if this was due to a language barrier or altered mental status.

Physical examination

The patient was alert. He was afebrile with a heart rate of 59 beats/minute, a respiratory rate of 16 breaths/minute, a blood pressure level of 147/102 mm Hg, and pulse oximetry of 98% on room air. He appeared well-nourished and well-developed. He was sitting comfortably, appearing to be in no acute respiratory distress. The patient’s head was atraumatic and normocephalic. There was no tenderness to palpation of his head and no midline cervical tenderness. However, his right pupil was 5 mm and nonreactive, and his left pupil was 3 mm and minimally reactive. His extraocular movements appeared to be intact.

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He was in a cervical collar, and no cervical deformities were noted. His chest was symmetric and nontender to palpation, and there were no deformities of the chest wall. His lungs were clear to auscultation, and his heart rhythm was irregularly irregular. His abdomen was soft, nontender, and nondistended, and he was able to move all extremities. On neurologic examination, the patient opened and closed his eyes. Sensation was unable to be assessed due to the language barrier. His Glasgow Coma Scale (GCS) score at this time was 14. An interpreter was paged to attempt translation for the staff as the patient was taken for CT of the cervical spine and brain.

Differential diagnosis

  • Subdural hematoma
  • Subarachnoid hemorrhage
  • Epidural hematoma
  • Cerebral mass