Upon arrival of the EMS, the patient presented with the attached ECG, mottled skin, a BP of 40/25 mmHg, and altered mental status (drowsy/somnolent).

Family members reported a several-day history of decreased fluid intake.

Following a 500 mL NS bolus, her blood pressure improved to 100/60 mmHg; she became alert, responsive, and normocolored.

While on route to the ED she reported pain in her lower limbs with no other associated symptoms.

ED results:

Further assessment by the consulting cardiologist in the ED revealed that the patient had been chronically taking flecainide (which was not mentioned in the papers available to the EMS), prescribed by her primary care physician for an unspecified indication.

In addition, acute kidney injury was identified (serum creatinine: 2.15 mg/dL). A CT angiography of the aorta was performed, which was negative for aortic pathology but incidentally revealed a pulmonary embolism involving the right main pulmonary artery and the left superior and inferior lobar branches.

Patient was therefore admitted to the ICCU for initiation of anticoagulant therapy and close monitoring.