Differential Diagnosis for 73-year-old Male with Progressive Symptoms

The patient presents with a complex set of symptoms including gait instability, confusion, swallowing difficulties, and a history of a recent fall. Considering these factors, the differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis

  • Chronic Subdural Hematoma: Given the patient's history of a fall approximately six weeks ago, a chronic subdural hematoma is a highly plausible diagnosis. The symptoms of gait instability, confusion, and worsening condition over time are consistent with this condition, especially in the elderly where even minor trauma can lead to significant intracranial complications.

• Other Likely Diagnoses

  • Progression of Parkinson’s Disease: The worsening of symptoms such as gait instability and confusion could be attributed to the natural progression of Parkinson’s disease. However, the acute onset and the specific combination of symptoms, including swallowing difficulties, might suggest another underlying cause.
  • Normal Pressure Hydrocephalus (NPH): NPH can present with gait disturbances, dementia, and urinary incontinence. While the patient's symptoms partially align with NPH, the absence of urinary incontinence and the recent history of head trauma make this diagnosis less likely but still a consideration.
  • Medication Non-adherence: In patients with Parkinson’s disease, non-adherence to medication can lead to a worsening of symptoms. However, the presence of confusion and swallowing difficulties, which are not typical symptoms of Parkinson’s disease fluctuation, suggests that other factors might be at play.

• Do Not Miss Diagnoses

  • Chronic Subdural Hematoma: Although already mentioned as the single most likely diagnosis, it's crucial to reiterate its importance due to the potential for severe consequences if missed, including increased intracranial pressure, brain herniation, and death.
  • Intracranial Infection or Abscess: Although less likely, an intracranial infection could present with similar symptoms, especially confusion and worsening neurological status. Given the patient's age and potential for compromised immune status, this diagnosis should not be overlooked.

• Rare Diagnoses

  • Vascular Dementia: While less likely given the acute onset, vascular dementia could be considered, especially if there were evidence of previous strokes or vascular disease.
  • Prion Disease: Conditions like Creutzfeldt-Jakob disease are rare but can present with rapidly progressive dementia, ataxia, and myoclonus. The absence of myoclonus and specific diagnostic markers makes this diagnosis less likely but should be considered in the differential of rapidly progressive neurological decline.