A 65-year-old man with severe hyponatremia and alcohol abuse.

On arrival to the ED, his vital signs included the following: temperature, 35.3°C; heart rate, 106 beats min; BP, 186 100; and respiratory rate, 18 breaths min. On examination, the patient was disheveled, in no acute distress, and appeared his stated age. Examination revealed the following: chest, clear bilaterally; cardiac, tachycardic and regular with strong pulses, no peripheral edema, and fl at neck veins; neurologic, unintelligible speech, unable to follow commands but withdrawing to painful stimuli and moving extremities spontaneously; pupils 2 mm, symmetric and reactive. Muscle bulk was diminished in all extremities, with normal tone and normal, symmetric deep tendon refl exes.