Case 4: Clinical Discussion

Clinical History

HPI: 50 year old man who presents to his primary care physician with complaints of a gradual onset of frontal headaches and new onset seizures. His PMH is notable for 20 pack year smoking history.

Questions

1. What is your clinical differential diagnosis?

It is important to first entertain a broad differential based on categories of disease and then narrow the differential down based on the patient’s specific symptoms:

• Tumor: Primary brain tumor vs metastatic disease. Given the patient’s history of smoking, metastatic disease is high on the list.
• Infection: Cerebretis/Encephalitis with or without an abscess. Less likely given no history of fever or elevated WBC.
• Demyelinating Disease: Unlikely to present with seizures. Unusual age demographic for MS.
• Vascular: Acute ischemic arterial strokes typically do not present with seizures; venous infarcts however can present with seizures, especially if hemorrhagic.
• Hemorrhage: Certainly should be entertained, however given the gradual onset of symptoms, this also seems less likely.

2. What scan would you order next?

Answer