A 70-year-old female was brought to the emergency medicine department by her son with a history of altered sensorium for three days. On presentation, her airway was patent with 70% saturation on room air, and air entry was absent on the right lower lobe on auscultation. Her pulse was at 75/minute and 70 mm hg of blood pressure with raised jugular venous pressure (JVP). She was drowsy but followed commands with Glasgow Coma Scale (GCS) E3, V5, and M6. Her blood sugar level was 120 mg/dl. Babinski's sign was negative, deep tendon reflexes were diminished, and neck stiffness and rigidity were absent on examination. Her extremities were cold, with a body temperature of 35.5 C. On local examination, the patient was pale with facial puffiness, as shown in (Figures 1, 2)
Her abdomen was distended, there was a dull note on percussion, and bowel sounds were sluggish on auscultation. Propped-up position oxygen was started via Hudson mask at a rate of 14 lit /minute, and 12 lead ECG was done as shown in (Figure 3). 
Arterial Blood Gas (ABG) was done, which was suggestive of uncompensated respiratory acidosis, which gets improved after management initiation as shown in (Table 1).
There was a history of deep vein thrombosis of the left lower limb ten years back. The swelling persisted in the bilateral lower limb for ten years, and the patient was not on any treatment. She had no history of hypertension, diabetes mellitus, bronchial asthma, tuberculosis, hypothyroidism, seizures, or loss of consciousness. Blood samples were withdrawn for Complete blood count, liver function test, renal function test, D-DIMER, TSH, free T3, and free T4. Results are shown in Table 2. Figure 4 depicts the chest x-ray anterior-posterior (AP) view. CT brain plain was normal.
The patient was started on Inj Levothyroxine 20 mcg IV bolus and Inj Pantoprazole 40 MG IV. Inj unfractionated Heparin 5000 IU IV was given for pulmonary thromboembolism. Inj Piperacillin and Tazobactam 2.25 GM IV was given.The patient was shifted to the medical intensive care unit (MICU) for further management. After 12 hours, the patient was conscious and oriented to time, place, and person with GCS 15/15 and maintained a blood pressure (BP) of 100/60 mm Hg.