An Unresponsive 38-Year-Old Man

Lars Grimm, MD, MHS; Malkeet Gupta, MS, MD; Joshua M. Kosowsky, MD

Disclosures

March 15, 2016

Physical Examination and Workup

On arrival at the ED, the patient has a blood pressure of 88/40 mm Hg, heart rate of 38 beats/min, and respiratory rate of 24 breaths/min. An oral thermometer reading is unsuccessful, but a rectal probe records a temperature of 85.4°F (29.7°C). Repeated attempts to obtain an oxygen saturation measurement via a finger pulse oximeter are not successful.

Figure 1.

Upon initial examination, the patient appears to be a homeless, disheveled man with a faint smell of alcohol on his breath. His clothing is stained and extensively worn. He looks older than the stated age on his identification card.

In the ED, the patient is mildly arousable and has trouble following simple commands. He has intact gag and corneal reflexes and does not fight the examiner during the tests. He responds appropriately to painful stimuli. His pupils are equal, round, and reactive to light. No obvious signs of head trauma are noted, and his oropharynx, nares, and ears are unremarkable.

Cardiac examination is notable for marked bradycardia of 45 beats/min, but no murmurs, rubs, gallops, or extra heart sounds are noted. A lung examination reveals rhonchi and dullness to percussion in the right lower lung field, but otherwise normal lung sounds. The patient's abdomen is soft, nontender, and nondistended, and normal bowel sounds are heard. His skin is cold, and his fingers and toes have a bluish tinge, with a delayed capillary refill time. A brief skin survey reveals some minor abrasions, but no major wounds or erosions.

The patient cannot provide any additional information about his medical, family, medication, social, or allergy history. His pockets contain an identification card, but no other useful information.

Routine blood work is ordered. The results of the patient's metabolic panel are all within normal limits. His blood glucose level is 104 mg/dL (5.77 mmol/L). The complete blood cell count reveals a small elevation in the white blood cell count, but is otherwise unremarkable. A portable chest radiograph shows a small consolidation of the right lower lobe that is consistent with pneumonia.

An ECG is performed (Figure 1).

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