100 Cases in Clinical Medicine

CASE 53: LOSS OF CONSCIOUSNESS

History

An unkempt man of uncertain age, estimated to be 55–65 years, is brought in to hospital by
ambulance having been found unconscious on the pavement outside a pub on New Year’s
eve. There is no other available history. A used packet of paracetamol and dihydrocodeine is
found in one of his pockets but no illicit drugs and no means of identification.

On examination he looks pale and smells of alcohol and urine. There are no signs of head
injury and no localizing neurological signs.

Examination

Tendon reflexes are present and equal except the ankle reflexes which are absent. Plantar
responses are downgoing. The pupils are equal and reactive and the fundi look normal.
The observation chart is completed by the nurse in the emergency department.

• Pulse: 82/min


• Blood pressure: 92/56 mmHg


• Temperature: 35.1°C


• Respiratory rate: 12/min


• Oxygen saturation: 95 per cent breathing air


• Glasgow Coma Scale: 10/15


• Urine on catheterization: 450 mL volume;'sugar;'blood; no protein

The electrocardiogram (ECG) is shown in Fig. 53.1.

INVESTIGATIONS

I aVR V1 V4

II aVL V2 V5

III

II

aVF V3 V6

Figure 53.1Electrocardiogram.

Questions

• What is the likely cause of the problem?


• What investigations and treatment are indicated?