Unexplainably Altered Elder

Figure. Protocol ECG. (Click on figure to enlarge)

An elderly man is brought to the emergency department by ambulance after he was found in an altered state of consciousness in his apartment. The 911 call came from a “Meals on Wheels” (M-O-W) delivery driver who was worried when no one answered the door. The patient can give his first name, but not much more. The M-O-W driver told medics that the man is on a diabetic diet and that he had last brought him food 48 hours earlier. At that time the patient seemed fine but had mentioned that he had “a cold.”

Medics provide the following report: “We found him lying on the couch, incontinent of urine and stool, but with no evidence of trauma. Pulse 80 and regular, blood pressure 95/60 and glucose 499.” On examination he is lethargic with pupils that are symmetric and react sluggishly to light. His neck is non-tender and supple. His lungs have bilateral rales and ronchi but he is breathing at only about 12 respirations/minute. His heart sounds are normal. His abdomen is non-tender. His extremities have 1+ bilateral edema. His neurological exam is non-focal and he can move all extremities symmetrically but weakly.

The protocol ECG ordered by the charge nurse (Figure), is given to you by the EMT as you finish your exam.

Given what you note on the ECG tracing, what should you immediately order?

What's your diagnosis?

Please leave your answer(s) below, then click here for answer and discussion.