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Case 34
A 62 year-old man is brought to the ED after being found unconscious at the bottom of the stairs in front
of his apartment building. His landlord found him and called 911. In the field, BP 180/105, pulse 90,
GCS 9 (E2M5V2), with pupils 2mm and sluggishly reactive; an AV fistula was noted in his left antecubital
fossa. One amp of D50, naloxone and IV thiamine did not change his exam. He comes in on a
backboard, in a hard collar. In his wallet is a printout of his medications: metoprolol, amlodipine,
clonidine, calcium supplements, renal vitamins, vitamin D, and ferrous sulfate. On exam, there is a small
abrasion on his forehead, no signs of fluid overload and a thrill in his AV fistula. His GCS is now 5
(E1M3V1), with a dilated, sluggishly reactive right pupil and flexor posturing of the left arm.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor her condition and its treatment? What is the prognosis?
Case 34
A 62 year-old man is brought to the ED after being found unconscious at the bottom of the stairs in front
of his apartment building. His landlord found him and called 911. In the field, BP 180/105, pulse 90,
GCS 9 (E2M5V2), with pupils 2mm and sluggishly reactive; an AV fistula was noted in his left antecubital
fossa. One amp of D50, naloxone and IV thiamine did not change his exam. He comes in on a
backboard, in a hard collar. In his wallet is a printout of his medications: metoprolol, amlodipine,
clonidine, calcium supplements, renal vitamins, vitamin D, and ferrous sulfate. On exam, there is a small
abrasion on his forehead, no signs of fluid overload and a thrill in his AV fistula. His GCS is now 5
(E1M3V1), with a dilated, sluggishly reactive right pupil and flexor posturing of the left arm.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor her condition and its treatment? What is the prognosis?