What’s the Diagnosis?

Case of the Month

The New Physician January-February 2012

The case below is followed by a choice of diagnoses. Select the one lettered selection that best describes the patient's condition.

A 38-year-old man is brought to the emergency department by ambulance on a cold December morning (temperature outside was about 35°F [1.7°C]), with winds of 10–15 miles per hour (16.1–24.1 kilometers per hour). He was found by bystanders unresponsive and sprawled on the stoop of an apartment building. No additional history was available. En route, he was wrapped in multiple blankets and administered 0.5 L of normal saline intravenously.

Cases Figure 1On arrival, his vital signs show a blood pressure of 88/40 mm Hg, a heart rate of 38 bpm, and a respiratory rate of 24 breaths/ min. A core rectal temperature of 85.4°F (29.7°C) is recorded. Repeated attempts to obtain an oxygen saturation measurement are unsuccessful. The patient appears to be disheveled, with the faint smell of alcohol on his breath. He responds to verbal stimuli with grunts and has trouble following simple commands. He has an intact gag and symmetric corneal reflexes. He responds to painful stimuli by pushing the hands of the examiner away. No obvious signs of head trauma are noted, and his oropharynx, nares, eyes and ears are unremarkable. On cardiac examination, bradycardia is noted, without any murmurs, rubs or gallops. Rhoncherour breath sounds are heard throughout, and dullness to percussion is present in the right lower lung field. His abdomen examination is normal. The patient's 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. The patient is unable to provide any additional information. His pockets contain an identification card, but no other useful information.

Routine blood work is ordered; significant findings include a blood glucose of 104 mg/dL (5.77 mmol/L) and a small elevation in the white blood cell count. A chest radiograph shows a small consolidation of the right lower lobe consistent with pneumonia.

What is the diagnosis?

A. Hyperkalemia

B. Hypothyroidism

C. Hypothermia

D. Acute myocardial infarction

HINT: Note the condition the patient was found in and the physical examination.


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