What’s the Diagnosis?
Case of the Month
The New Physician January-February 2012
Source: Medscape (Medscape.com), © 2011Volume 61, Number 1
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.
On 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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