Approach to altered mental status Quiz: Ace Your Exams

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A 68-year-old man is brought to the emergency department by his partner after she found him difficult to arouse from bed this morning. The partner reports that over the past three days, the patient has become progressively more lethargic and confused. He recently developed progressive shortness of breath and a cough productive of yellow sputum. He has a history of chronic obstructive pulmonary disease (COPD) and chronic lower back pain managed with low-dose oxycodone. He has a 50-pack-year smoking history. Temperature is 37.8 °C (100.0 °F), pulse is 114/min, respiratory rate is 30/min, blood pressure is 148/90 mmHg, and oxygen saturation is 85% on 4L/min nasal cannula. The patient is difficult to arouse, and there is pooling of saliva in the mouth. Gurgling noises are noted with each breath, and the patient is using accessory muscles of respiration. Pupils are equal, round, and reactive to light. The patient is using accessory respiratory muscles to breathe. Pupils are equal, round, and reactive to light.  Cardiopulmonary exam is significant for diffuse wheezes bilaterally. Arterial blood gas analysis is shown below. What is the best next step in management? 

 Parameter      Value     
 pH      7.18     
 PaCO2      82 mmHg     
 PaO2      45 mmHg     
 HCO3-      31 mEq/L     

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