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A year-old attorney was referred with a chief complaint of headaches and vomiting.

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History of Chief Complaint The patient had had frontal and biparietal headaches for approximately one month. Coughing, sneezing, or bending precipitated the headaches. On at least one occasion the patient had been awakened by a headache. He experienced nausea and vomiting independent of the headaches.

At times, vomiting occurred suddenly without preceding nausea. For several weeks prior to admission he had been unsteady on his feet with a tendency to fall to the right.

He admitted to occasional clumsiness of his right hand. During the week prior to admission he had been excessively drowsy and constantly tired. The headaches had become more frequent, so that they were now occurring three to four times per day. Medical History His medical history was unremarkable except for an episode of rheumatic fever at age 6.

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Family History He was unmarried, lived alone, and was employed by a large law firm. His parents were alive and in good health; he had no siblings. Social History He professed to be heterosexual and was involved in a monogamous relationship that had lasted for several years.

He had a pack-year history of smoking, but had quit 6 years previously. He had been active in outdoor sports since age 31 and had been running up to 4 miles daily until 4 weeks before, when he had to quit because of an unsteady gait and headaches.

General Physical Examination This was an awake, oriented, well-nourished, well-hydrated, and distressed man in considerable pain.

He appeared the stated age and in otherwise good physical condition. His eyes had no cotton wool patches, but papilledema was evident.

His chest was clear to auscultation and percussion; his abdomen was soft without lumps or masses. Blood pressure, pulse rate, temperature, and respirations were normal. Peripheral pulses were intact; no edema was present; and no cervical, axillary, or inguinal lymphadenopathy was detected.

Neurologic Examination Mental Status. He was awake and oriented with respect to person, place, and time. His memory and knowledge base were appropriate for his training.

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