Differential Diagnosis for Patient with Fall and Head Injury

The patient's presentation with a stiff neck, headache, and neurological deficits after a fall and hitting their head suggests a range of possible diagnoses. The patient's current medications, clopidogrel and aspirin, which are antiplatelet agents, increase the risk of bleeding complications.

• Single Most Likely Diagnosis

  • Traumatic Subarachnoid Hemorrhage (SAH) or Epidural Hematoma: The patient's symptoms of stiff neck (suggestive of meningismus) and headache, combined with the history of a fall and hitting the head, make a traumatic SAH or epidural hematoma highly plausible. The inability to follow light to one side and weakness of the opposite arm (indicative of a possible third cranial nerve palsy and hemiparesis, respectively) could be due to increased intracranial pressure or direct injury to brain structures.

• Other Likely Diagnoses

  • Traumatic Brain Injury (TBI) with Concussion or Contusion: Given the mechanism of injury, a TBI is likely. Symptoms can range from mild (concussion) to severe (contusion with significant brain injury).
  • Cervical Spine Injury: The complaint of a stiff neck could also indicate a cervical spine injury, which is a concern in any patient who has fallen and hit their head.
  • Stroke (Ischemic or Hemorrhagic): Although less likely given the acute trauma, the patient's age and medications (clopidogrel and aspirin) could predispose to a stroke. The sudden onset of neurological deficits supports this possibility.

• Do Not Miss Diagnoses

  • Cervical Vertebral Artery Dissection: This is a potentially life-threatening condition that could lead to stroke. The mechanism of injury (fall and hitting the head) could involve neck trauma, making this a critical diagnosis not to miss.
  • Spinal Cord Injury: Any injury to the spinal cord could result in significant and potentially permanent neurological deficits. The inability to move one arm could be indicative of a spinal cord injury affecting the cervical spine.
  • Intracranial Aneurysm: Although less common, an aneurysm could rupture due to trauma, leading to a subarachnoid hemorrhage. This diagnosis is critical due to its high mortality and morbidity.

• Rare Diagnoses

  • Arteriovenous Malformation (AVM) Rupture: A pre-existing AVM could rupture due to the trauma, leading to hemorrhage.
  • Cerebral Venous Sinus Thrombosis: This condition, although rare, could be considered in the differential, especially if there are risk factors for thrombosis or if the patient's symptoms do not fit neatly into other categories.
  • Intracranial Infection (e.g., Meningitis): While less likely given the acute presentation after trauma, an infection could be considered, especially if there are signs of infection or a compromised immune system.

Each of these diagnoses requires careful consideration and appropriate diagnostic testing, including imaging studies (CT or MRI of the head and possibly the cervical spine), to determine the underlying cause of the patient's symptoms.