Uncovering The Source of a Headache Following a Fall

Introduction. A 50-year-old man presented to the emergency department (ED) after slipping on a wet stone surface while fishing at a beer festival. He presents with altered mental status and a vague symptom of headache.

History. The patient was transported via emergency medical services after a bystander called 911 after witnessing the patient fall. While in the ED, the patient was affable and made jokes with the staff while in no apparent distress. Although the patient was not visibly intoxicated, he was only able to somewhat articulate himself when communicating. When asked questions about his fall or the beer festival itself, the patient was unable to answer questions, saying “he wasn’t sure” or he would change the topic of conversation altogether. The patient endorsed having a headache but was unable to describe the characteristics or intensity of the headache. When the ER physician asked him “What is your name?” the patient responded with “Yes.” “What is the date today?” “Yes.” “Who is the president?” “Yes.” These answers demonstrated a change in the patient’s mental status from when he first presented. The ER physician immediately activated the call to the neurosurgeon team for a possible neurosurgical emergency.

According to the patient, he had no relevant past medical history, family history, or surgical history. All of which could not be confirmed due to limited patient records. 

On a physical examination, the only positive finding was a moderate-sized subcutaneous hematoma, approximately 5 cm in diameter, on the right lateral aspect of the head. Pupils were bilaterally equal and reactive. Facial symmetry was normal. Strength in the extremities was 5/5. Tendon reflexes were +2 bilaterally. Heart and lungs were normal.

Diagnostic Testing. The patient’s head CT without contrast showed a hyperdense crescent along the convexity of the brain extending into adjacent cranial compartments. Complete blood count, basic metabolic panel, vitals, and urine toxicology were within normal limits. The patient had a blood ethanol level of 200 mg/dL. Normal blood ethanol levels are <80 mg/dL, with values of 80 or above designated as intoxicated by US law.