What is the most likely cause of a 21-year-old male's inability to stand or walk with general weakness, no loss of consciousness, and two hypodense brain lesions on computed tomography (CT) scan, two weeks after a fall onto his head, considering his history of working as a shepherd and stopping more than six months ago?

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Differential Diagnosis

  • Single most likely diagnosis
    • Chronic subdural haematoma: This is the most likely diagnosis given the patient's history of a fall two weeks prior to presentation, with gradual onset of symptoms such as general weakness and inability to stand or walk, without loss of consciousness or severe headache. The CT image showing two hypodense brain lesions also supports this diagnosis, as chronic subdural hematomas often appear hypodense due to the breakdown of blood products over time.
  • Other Likely diagnoses
    • Subacute subdural haematoma: This could be considered if the symptoms had developed sooner after the fall, but the two-week timeframe still makes it a possibility. However, the lack of severe symptoms initially and the gradual onset make chronic subdural hematoma more likely.
    • Acute subdural haematoma: Less likely given the timeframe and the nature of the symptoms. Acute subdural hematomas typically present immediately after a traumatic event with severe symptoms.
  • Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
    • Extradural haemorrhage (Extradural hematoma): Although less likely given the timeframe and the description of the CT findings, an extradural hematoma can be life-threatening and requires immediate intervention. It's crucial to consider this diagnosis, especially if there's any suspicion of a significant head injury.
  • Rare diagnoses
    • Other intracranial pathologies (e.g., tumors, abscesses, or cysts): While rare, these conditions could potentially present with similar symptoms and hypodense lesions on CT. However, the history of a recent fall makes a traumatic cause more likely.
    • Infectious or inflammatory conditions: Conditions such as encephalitis or meningitis could present with weakness and altered mental status but would typically have additional symptoms such as fever, headache, or stiff neck, and different findings on imaging.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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