A 63-year-old male is unresponsive when brought to the Emergency Department by his wife. His wife states that he complained of an acute onset of severe headache, that caused him to collapse. She also recounts that, as he tried to explain his symptoms to her, the patient's speech was slurred. She doesn't recall her husband having had an episode like this before; however, she indicates that he is unwilling to discuss what he is feeling, and that she has to 'pull everything out of him' if she wants to know more. She remembers that the patient did complain of chest tightness while they were playing tennis several months ago. She also recalls her husband describing an episode of hematuria about a year ago. He refused her pressure to seek medical attention, even after he had a recurrence of hematuria. The patient had been an athlete in college and regularly exercises, including morning walks of several miles. She states that he avoids regular medical care. She can only recall one visit for a medical evaluation: a pre-employment physical over ten years ago, when her husband told her 'all was well.' The patient takes no medication, except a baby aspirin daily, which a physician friend told him would be good for his heart.

General Appearance: No response to verbal stimulus. Blood pressure 185/115 taken from both arms while supine. Heart rate is 52, and respiratory rate is 16, but with periods of deep and fast breathing. The patient is 6' tall, and weighs approximately 183 lbs. Other pertinent physical findings are as follows:

Neurologic: Unable to fully assess due to unresponsiveness. There is withdrawal to painful stimulus on the right side, but not on the left. The right pupil is dilated and does not react to light. The left pupil is normal in size, and reactive to light.

Genital/Rectal: Prostate smooth, symmetrical, non-tender, and moderately enlarged.

Cardiovascular: Apical impulse is larger and more forceful than normal (LV heave) but not displaced.

Sodium: 142 mmol/L	normal: 136-145 mmol/L
Potassium: 4.4 mmol/L	normal: 3.5-5.0 mmol/L
Albumin: 3.8 g/L	normal: 3.5-5.5 g/L
WBC: 4.9 x103/mm3	normal: 4.5-10.5 x103/mm3
Hgb: 17.8 g/dL	normal: 13.5-17.5 g/dL
Glucose: 103 mg/dL	normal: 70-110 mg/dL
BUN: 35 mg/dL	normal: 7-18 mg/dL
Creatinine 1.5 mg/dL	normal: 0.6-1.2 mg/dL
Creatine kinase MB (CKMB): 3 ng/mL	normal: 0-4 ng/mL
Troponin: 0.3 ng/mL	normal: 0.0-0.4 ng/mL
BNP: 88 pg/mL	normal: 0.5-30 pg/mL

The patient remains unresponsive to voices or commands during his very short stay in the ED. He begins to undergo seizure, and cardiopulmonary function cannot be maintained.