A 26-Year-Old Man Who Passed Out at His Work Desk

Craig A. Goolsby, MD


May 18, 2023

Physical Examination and Workup

Upon physical examination, the patient has an oral temperature of 96.5°F (35.8°C). His heart has a regular rhythm and a rate of 96 beats/min. His blood pressure is 134/76 mm Hg, and his respiratory rate is 16 breaths/min. He has a pulse oximetry reading of 100% on 15 liters via nonrebreather mask.

In general, the patient appears obtunded. He is not making any sounds, but he does open his eyes briefly and withdraws from painful stimulation (sternal rub only). His motor, verbal, and eye findings give him a Glasgow Coma Scale score of 7. He is breathing spontaneously and appears to be controlling his airway secretions. The patient has no signs of trauma on head-to-toe examination. His pupils are large at about 5 mm bilaterally, but they react equally to light. He has no meningismus, thyroid masses, or neck scars. Clear bilateral breath sounds are noted. He has a soft abdomen, without any peritoneal signs. His skin and mucous membranes appear dry. No rashes are detected. His distal extremities are warm, with normal capillary refill. No needle track marks are noted on his extremities.

The patient receives 0.4 mg of intravenous naloxone, without any change in his condition. A fingerstick glucose test has a result of 105 mg/dL (5.83 mmol/L). He undergoes rapid sequence intubation for airway protection, as well as for an anticipated worsening course. A chest radiograph shows appropriate endotracheal and orogastric tube placement; no acute cardiopulmonary disease is detected. He receives a dose of activated charcoal via orogastric tube and a liter of normal saline intravenously. Laboratory studies are ordered. A stat CT scan of the head is ordered but does not reveal any abnormalities or disease. An electrocardiogram (ECG) is ordered as well (Figure 1).

Figure 1.


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