An 88 y/o previously healthy man presented via EMS after being found on the floor next to his bed. EMS called by daughter who went to check on dad (lived alone) and found him unconscious on the floor. Patient previously seen one day earlier and was ‘acting normal’ per daughter.

Per EMS, they arrived to find the patient with a pulse of 35, blood pressure of 60 palpable, and semiconscious (patient would open eyes transiently, mumbled incomprehensible words, and did not respond to pain (GCS = 2 (eyes) + 2 (verbal) + 1 (motor) = GCS 5)

EMS was unable to get an IV established.

PMH: Hypertension on a beta blocker, arthritis treated with Tylenol PRN

SH: Lives alone, does all ADL’s (activities of daily living)independently, no smoking. Uses a stair ‘lift’ to get up the steps to his second story bedroom (has ‘bad hip arthritis’).

PE: Elderly man, appearing well nourished and younger than his years. No cyanosis or respiratory distress.

HR = 37 RR = 12 BP = 65/40 T=afebrile Sat: not picking up

PERRL

Neck non tender

Heart RRR, slow. Monitor showing sinus bradycardia

Lungs: Decreased BS (decreased effort?) no rales/Wheezing

Abd: Obese, non tender, no AAA

Ext: No cyanosis, edema

Neuro: Unable to answer questions, occasional inappropriate moaning. Unable to test cranial nerves (will not follow commands) but no obvious focal deficit. Motor/sensory exam: no response to pain. Reflexes: absent at patella, achielles, and biceps.

1. What is the differential diagnosis?

2. Any additional exam helpful?

3. What mistake did I make?

4. How often do patients with this condition present in shock?

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