A 37 years old male with history of alcohol abuse was brought by his girlfriend to the emergency department after being found collapsed in his apartment after they had a big fight .His brother has a history of depression
On examination he was drowsy. Afebrile, blood pressure 96/60 mm Hg, pulse 132 /min, respiratory rate 18 /minutes, His pupils were dilated and reacted very sluggishly to light, with lateral tongue laceration.
Neurological exam showed hypertonia in all four extremities, reflexes were brisk, and the planters were both up going. Abdominal examination revealed a firm palpable mass 5 cm above the symphysis pubis
Lab studies: Hemoglobin 16 g/dL, Hct 43 %, platelets 295 x10⁹/l, MCV 102 fl, sodium 142 meq/L, potassium 4 meq/L, chloride 110 meq/L ,bicarbonate 20 meq/L ,urea 11mg/dL, Creatinine 1.3 mg/dL, plasma glucose 108 mg/dL, calcium 9.6 mg/L, phosphate 4 mg/dL, Billirubin 0.7 mg/dL, AST 33 U/L , alkaline phosphatase 120 U/L, plasma osmolality 338 mOsm/kg H2O, urine osmolality 122 mOsm/kg H2O
EKG revealed wide QRS, terminal right axis deviation. Prolonged QT interval and sinus tachycardia
1-What is the most likely clinical diagnosis?
2-What is the best next investigational study which is going to help you to manage this patient?
3- What are the best next 7 steps to manage this patient?