Question

A 56 year old woman was admitted to hospital due to complaints of headache, dizziness, vomiting and foot paralysis. A few days before admission, she had developed severe abdominal pain and vomiting. Her blood pressure was 110/70 mmHg and pulse rate, 84 beats/min. Neurological examination showed no abnormal findings. Proximal muscle weakness was noted in the upper and lower limbs. There was no history of tetany, and Chvostek’s sign and Trousseau’s sign were negative.

On presentation:

Biochemistry, serum:

Test​Result​ Reference range

​

​Sodium​ 140​mmol/L​ (135-145 mmol/L)

​Potassium​ 1.70​mmol/L​ (3.6-5.0 mmol/L)

​Chloride​ 90.0​mmol/L​ (98-107 mmol/L)

​Calcium​ 2.35​mmol/L​ (2.15-2.5 mmol/L)

​Phosphate​ 0.29​mmol/L​ (0.87-1.45 mmol/L)

​Magnesium​ 0.36​mmol/L​ (0.63-1.0 mmol/L)

​Urea​ 5.0​mmol/L​ (2.5-7.0 mmol/L)

​Creatinine​ 82.8​mmol/L​ (70-110 mmol/L)

​Total Bilirubin​ 15​µmol/L​ (3-17 µmol/L)

​AST​ 174​U/L​ (˂30 U/L)

​ALT​ 92​U/L​ (˂37 U/L)

​LDH​ 595​U/L​ (100-225 U/L)

​CK​ 244​U/L​ (145 U/L)

Biochemistry, urine:

​ Test​Result​ Reference range

​

​Sodium​ 99​mmol/L​ (40-220 mmol/L)

​Potassium​ 25.4​mmol/day​ (25-125 mmol/day)

​Chloride​​ 124​mmol/day​ (110-250 mmol/day)

​Calcium​​ 0.88​mg/day​​ (4.6-5.3 mg/day)

​Creatinine​ 447.2​mg/day​​ (500-2000 mg/day)

Blood Gas analysis:

Test​Result​ Reference range

​

​pH​ 7.6 (7.35-7.45)

​pCO2​ 5.9​KPa​ (4.6-6.0 KPa)

​pO2​ 9.5​KPa​ (10.7-14.6 KPa)

​HCO3-​ 41.6​mmol/L​ (22-26 mmol/L))

Endocrinological examination:

Test​Result​ Reference range

​

​ACTH​ 3.08 pmol/L​ (1.3-13.7 pmol/L)

​Cortisol​ 477.6 nmol/L​ (100-552 nmol/L)

​Aldosterone​ 582 pmol/L​ (54.9-388 pmol/L)

​Plasma rennin

activity​ >20 ng/mL/hr​ (1.0-3.8 ng/mL/hr)

​TSH​ 1.22 µU/mL​ (0.5-5.0 µU/mL)

T3​ 3.0 µmo/L​ (2.99-8.9 µmo/L)

​

Questions

Critically evaluate the patient on presentation and on the basis of these findings discuss the fundamental problem present. In your answer discuss how the clinical history and the biochemical results aided your evaluation of the diagnosis.

Answer 1

The laboratory findings which were abnormal in the reports were mainly potassium, chloride, phosphate and magnesium. All the lab values were below the normal that can present as hypokalaemia, hypochloridaemia, hypophosphatemia, hypomagnesemia. Which has been precipitated by the clinical manifestation such as foot paralysis, vomiting, dizziness and abdominal pain.

The other abnormal results were

AST​ 174​U/L​ (˂30 U/L)

​ALT​ 92​U/L​ (˂37 U/L)

​LDH​ 595​U/L​ (100-225 U/L)

​CK​ 244​U/L​ (145 U/L)

All of them were high which indicates some kind of tissue damage which were the manifestation of the headache and abdominal pain.

The urine analysis has the abnormalities in

Calcium​​ 0.88​mg/day​​ (4.6-5.3 mg/day)

​Creatinine​ 447.2​mg/day​​ (500-2000 mg/day)

Both of them were in the lower indicating a lower level in the blood itself

Blood gas analysis were able to provide important information

pH​ 7.6 (7.35-7.45)

pO2​ 9.5​KPa​ (10.7-14.6 KPa)

​HCO3-​ 41.6​mmol/L​ (22-26 mmol/L))

Clear cut evidence of respiratory alkalosis which is suggestive of the hypokalaemia

Endocrinological shows abnormalities in

Aldosterone​ 582 pmol/L​ (54.9-388 pmol/L)

Plasma rennin

activity​ >20 ng/mL/hr​ (1.0-3.8 ng/mL/hr)

That is why the blood pressure was measured tom be in the lower side of the normal that is 110/70