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On presentation, the patient’s blood pressure is 109/76 mm Hg, heart rate is 49 bpm, respiratory rate is 19 breaths/min, rectal temperature is 91.22°F (32.9°C), and oxygen saturation is 98%. The patient is noncommunicative and in mild distress. His pupils are equal, round, and sluggishly reactive to light. The cardiovascular examination is notable for a bradycardic regular rhythm, without murmurs. The distal pulses are faint but appreciable bilaterally. His respiratory rate and effort are normal and the lungs are clear to auscultation bilaterally. The abdomen is soft, nontender, nondistended, and with normal bowel sounds. The rectal examination reveals guaiac-positive brown stool. The patient’s skin is cool, dry, and nonedematous. He is nonverbal, but does turn his head in response to his name. The initial work-up includes an electrocardiogram (ECG), chest radiograph, complete blood cell count (CBC), basic metabolic panel (BMP), urinalysis, and cardiac enzymes. The ECG (Figure 1) shows a bradycardic junctional rhythm at a rate of 49 bpm (compared with previous ECGs showing a normal sinus rhythm with a rate in the 80s) and a prolonged QT interval. The CBC shows a normal white blood cell and platelet count, but a hemoglobin of 8.5 g/dL (85 g/L; decreased approximately 2 g/dL from a previous admission). The BMP shows stable stage 4 chronic kidney disease and a blood glucose level of 102 mg/dL (5.7 mmol/L). The cardiac enzyme examination and urinalysis are normal. Chest radiography shows mild vascular congestion and no infiltrates. Computerized tomography (CT) scanning of the head reveals no acute disease. The patient’s heart rate throughout the initial ED evaluation ranges from the high 40s to the low 60s. The patient receives a transfusion of packed red blood cells (RBCs). His hypothermia is treated with the application of warming blankets. The patient is re-evaluated and found to have a Glasgow Coma Scale (GCS) rating of 9. His blood glucose is rechecked and is 49 mg/dL (2.72 mmol/L). The low blood glucose is treated but the patient’s mental status does not improve. He continues to be hypothermic and bradycardic. He is endotracheally intubated for airway protection and admitted to the medical intensive care unit (MICU). Based on the constellation of symptoms, what is the most likely primary diagnosis? (Hint: Pay special attention to presenting complaint, current medications, and vital signs)
SCIENCE
HEALTH SCIENCE
NURSING

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