Instructions
You are a medical student on placement in the emergency department. Rosaria Benedetti, 74, has felt tired and generally unwell for three weeks and fell at home this morning, without hitting her head. HR 92, BP 128/74, RR 16, SpO2 97%, T 36.6. Her bloods and ECG are printed for you.
Interpret the results provided
Outline to the examiner:
- Your findings
- Your most likely diagnosis
- You do not need to take a history or examine the patient
- The examiner will ask you questions once you have stated your diagnosis
GP referral
Three weeks of tiredness, cramps in the calves and hands, tingling in the fingers and around the lips, and a fluttering heartbeat. Potassium 3.1 two weeks ago, so potassium tablets were started. No diarrhoea or vomiting. One or two glasses of wine a week.
Medicines
Esomeprazole 40 mg daily (6 years, for reflux); furosemide 40 mg each morning (8 months, for ankle swelling); slow-release potassium chloride 1200 mg twice daily (2 weeks); paracetamol 1 g up to four times a day when needed
Triage nurse note
This morning her heart raced, she felt light-headed and her legs gave way. Her hand cramped into a spasm while the blood pressure cuff was inflated.
Bloods (ED, today)
Na 137 mmol/L; K 2.9 mmol/L (3.5-5.2); Cl 97; HCO3 30; urea 5.8 mmol/L; creatinine 74 umol/L; eGFR 68; Mg 0.36 mmol/L (0.70-1.10)
Bloods (ED, today), continued
Total Ca 1.88 mmol/L (2.20-2.60); corrected Ca 1.92 mmol/L; albumin 38 g/L; phosphate 0.90 mmol/L (0.75-1.50); PTH 2.1 pmol/L (1.6-6.9); CK 95 U/L
ECG (ED, today)
Sinus rhythm 92, PR 168 ms, QRS 88 ms, axis +30. Occasional ventricular ectopic beats. Sagging ST depression 0.5 mm in V4-V6. Flattened lateral T waves, U waves V2-V4. QTc 510 ms (under 460)
Bloods (ED, today)
| Item | Value | Reference range |
|---|---|---|
| Sodium | 137 mmol/L | 135-145 mmol/L |
| Potassium | 2.9 mmol/L | 3.5-5.2 mmol/L |
| Chloride | 97 mmol/L | 95-110 mmol/L |
| Bicarbonate | 30 mmol/L | 22-32 mmol/L |
| Urea | 5.8 mmol/L | 3.0-8.0 mmol/L |
| Creatinine | 74 umol/L | 45-90 umol/L |
| eGFR | 68 mL/min/1.73m2 | >60 mL/min/1.73m2 |
| Magnesium | 0.36 mmol/L | 0.70-1.10 mmol/L |
| Calcium (total) | 1.88 mmol/L | 2.20-2.60 mmol/L |
| Albumin | 38 g/L | 35-50 g/L |
| Corrected calcium | 1.92 mmol/L | 2.20-2.60 mmol/L |
| Phosphate | 0.90 mmol/L | 0.75-1.50 mmol/L |
| PTH | 2.1 pmol/L | 1.6-6.9 pmol/L |
| CK | 95 U/L | <170 U/L |
ECG (ED, today)
| Item | Value | Reference range |
|---|---|---|
| Rate | 92 bpm | 60-100 bpm |
| Rhythm | Sinus rhythm with occasional ventricular ectopic beats | - |
| Axis | Normal (+30 degrees) | - |
| P waves | Normal | - |
| PR interval | 168 ms | 120-200 ms |
| QRS duration and morphology | 88 ms, normal morphology | <120 ms |
| ST segments | Sagging ST depression of 0.5 mm in V4-V6 | - |
| T waves | Flattened in the lateral leads, followed by prominent U waves in V2-V4 | - |
| QTc | 510 ms | <460 ms |