Scenario 1 – Part 1:

A 27-year-old male presents with aching in his thighs and weakness of both lower limbs. The patient experienced painful spasmodic contraction of his calf muscles through the past few days. On examination, the patient appeared muscular, but he was unable to walk. He had generalized tenderness in all his skeletal muscles. The patient admitted that he was previously healthy and used to regularly practice handball and swimming. 

Review of the patient’s Laboratory investigation revealed:

Test

Value

S. Creatinine

1.1 mg/dL

S. corrected Calcium 

8  mg/dL

S. Phosphorus

3.2 mg/dL

S. potassium

2.5 mg/dl

iPTH

53 pg/mL

S. Magnesium

0.5 mmol/L  

 

A. Interpret the above laboratory investigation

B. Would you recommend further investigations for this patient?

37 Comments

  • Radwa Ellisy


    A. the patient has hypokalemia, mild hypocalcemia and severe hypomagnesemia, normal iPTH and phosphorus

    these disturbance espicially the hypokalemia and hypomagnesima coul explain the ptient’s complaints

    B. Yes, I would recommend  ABG, 24-hour urinary potassium and magnesium before correction of the deficits

    by reviewing the patient’s medications especially diuretics and  PPIs

  • Marwa Alm


    Hypomagnesemia associated with hypokalemia and hypo-calcemia
    Further investigations: ECG, VBG, FEMg, UCa/Cr ratio

  • Muhammad Soobadar


    hypokalaemia and hypomagnesemia causing muscle weakness
    low mg can impairment na/k/atpase leading to decrease k

    fractional excretion of mg and k

  • Areij Alotaibi


    1- hypokalemia with hypomagnesemia
    2- need 24 hours mg and creatinine

  • Mohamed Abdulahi Hassan


    hypoklemia and hypomagnesemia
    yes i would recommend to test tsh, 24 hrs urinary magnesium.
    ecg

  • Mohammed Farag


    Severe hypomagnesemia and hypokalemia
    24hr urinary mg and creatinine

  • Mahmoud Sobh


    Model answer approved by the board:
    Interpret the above laboratory investigation
    Normal previous lab investigations except for severe hypomagnesemia and hypokalemia which contribute to muscle tenderness , weakness and0/or muscle paralysis. Magnesium deficiency impairs Na-K-ATPase, which would decrease cellular uptake of potassium.
    Hypokalemia may in turn directly inhibit distal tubular cell magnesium uptake, thereby increasing magnesium excretion.

    Would you recommend further investigations for this patient? 

    Obtain 24 hour urinary magnesium and 24 hour urinary creatinine or FEMg in spot urine .
    IF FEMg < 5% or 24 hour urinary magnesium <10 gm , consider GI loss or celullar uptake.
    IF FEMg > 5% or 24 hour urinary magnesium >10 gm, consider urinary loss

  • Khaldon Rashed Ahmed Moqbil


    A- ⬇️. K and mg
    B- history focuses loss mg and k
    check excration ca + mg from kidney 24 hours
    TFT
    VBG
    ECG

  • Asma Aljaberi


    A. Interpret the above laboratory investigationYoung patient with hypokalemia, hypomagnsemia, and hypocalcemia.

    B. Would you recommend further investigations for this patient?
    I would like to take more history if this patient was on PPI recently, and check his BP level. I would order bicarb level, TFT, Aldosterone/renin ratio, and 24hrs urine Ca, Mg.

  • HASSAN ALYAMMAHI


    Patient has hypokalemia and hypomagnesemia
    patient needs urinary and fecal calcium, magnesium and potassium to check whether there is renal or GIT losses.
    TFT
    ABG
    LFT

    Magnesium should be administered in addition to potassium

  • Rania Mahmoud


    A. Interpret the above laboratory investigation
    hypomagnesemia and hypokalemia
    normal creatinine and phosphorus
    B. Would you recommend further investigations for this patient?
    History and examination
    24 hour urinary calcium, magnesium and potassium to check whether there is renal or GIT losses.
    Thyroid function test
    ECG
    ABG
    LFT
    Thyroid function test
    Magnesium should be administered in addition to potassium

  • Mahmoud Elsheikh


    Interpretation :
    –       hypokalemia and hypomagnesemia
    –       normal po4 and PTH and renal function
     
    Further investigation:
    –       medication history
    –       TSH
    –       24 hr urine ca and mg

  • Asmaa Salih KHUDHUR


    I think this is a case of AR familial hypomagnesemic hypercalciuric hypocalcemia with nephrocalcinosis .
    there is low Mg
    mild reduced Ca
    hypokalemia.
    I need to do 24 hr urinary Mg and ca.
    BGA
    Abdominal US to ruled out Nephrocalcinosis.
    more detailed history of polyuria and polydipsia and family history as well.

  • Hagar Ali


    A)case of hypo mg, hypo k and hypo ca
    B)full history and renal excretion of mg and k

  • Riaan Flooks


    A: Hypomagnesemia and Hypokalemia

    B: Do a 24hr urine collection for Mg and Creatinine

  • Rihab Elidrisi


    This patient has hypoMg and HYPOk and mild Hypo Ca
    we need to do full work up ??? with full work in regards of Renal excretion of Mg and K

  • ahmed bhnassi


    case of hypo kalmia low mg low ca
    normal pth normal renal function
    need drug history family history complete urine electrolyte and serum albumin thyroid profile
    urine mg/creat ratio

  • Riaan Flooks


    A: INTERPRETATION
    Severe Hypomagnesemia with an associated Hypokalemia

    B: This patient requires further investigation. Enquire about any drugs/medication use, and any family history of any electrolyte disorder
    Do a Ca, PO4 and s-Albumin
    If the above is inconclusive, do a 24hr urine collection for Mg and Creatinine. This can be substituted by a Fractional Excretion of Magnesium

  • Rabab ALaa Eldin keshk Rabab


    A.interpretation of lab hypokalemia and hypomagnesemia with normal po4 and pth and renal function.
    B. Further investigation need medication history then need tsh 24 hr urine ca and mg

  • Alaa Abdel Nasser


    Lab shows: Hpokalemia, hypomagnesemia and mild hypocalcemia with normal serum creatinine, pi and PTH

    Would you recommend further investigations for this patient?

    measure 24 hour urinary magnesium and potassium

  • Nour Al Natout


    A. Hypomagnesemia, hypocalcemia, hypokalemia
    B. 24 hours Urin for magnesium, potassium, and calcium
    a BGA to exclude RTA.
    Medical history

  • Amna Kununa


    A. Interpret the above laboratory investigation:

    • Profound hypomagnesemia, hypokalemia, and hypocalcemia, with normal iPTH.
    • Hypomagnesemia is often associated with:

    *hypoK (due to urinary potassium wasting)
    *hypoCa (lower PTH secretion =/- end-organ resistance to its effect).

    B. Would you recommend further investigations for this patient?

    The cause of hypoMg usually is obtained from the history (GI or renal losses).

    • if there is no clear cause, measuring the 24-hour urinary magnesium excretion or the fractional excretion of magnesium on a random urine specimen help in the distinction between gastrointestinal and renal losses.

    Renal magnesium excretion should be reduced in patients with plasma magnesium depletion.

    So:

    • A daily excretion of >10 – 30 mg (in a 24-hour urine specimen) or a FEMg >3 – 4% in a person with hypomagnesemia and normal kidney function indicates renal magnesium wasting.
    • But if, a 24-hour urinary magnesium excretion <10 mg or a FEMg <2% usually indicates an extrarenal source of magnesium losses (GI).
  • KAMAL ELGORASHI


    The interpretation
    This hypomagnesemia induces severe symptomatic hypokalemia
    Recommended investigation
    Complete renal electrolytes panel.

  • Mark Nagy Zaki Amin Mark


    A- a case of hypocalcemia , hypokalemia and hypomagnesemia
    B- 24 hour urinary calcium to exclude familial hypomagnesemia with hypercalciuria

  • Israa Hammoodi


    A. He has hypokalemia, hypocalcimia and hypomagnesemia.
    He is muscular that makes his s. Creatinine increase
    B. S. Electrolyte Na, K and chloride
    Blood gas analysis
    Urinary mg, K, CA

  • Ahmed Altalawy


    A. Interpret the above laboratory investigation ;

    Hypokalemia, hypomagnesemia and hypocalcemia.

    B. Would you recommend further investigations for this patient?

    Investigate urinary potassium and magnesium in excretion in urine .

  • Elsayed Ghorab


    young pt. c/o generalized skeletal muscle pain his lab revealed
    hypokalemia , hypomagnesemia mild hypophosphatemia .PTH win normal ,and RFT normal

    plan
    ask about hist. of medication as diuretic and evaluate of nutritional status
    recommended for investigation of vitD -ABG – Liver enzymes – blood sugar and urinary k. Mg

  • Weam El Nazer


    A. Interpret the above laboratory investigation
    Symptomatic severe hypokalemia, hypomagnesemia, and mild hypocalcemia.

    B. Would you recommend further investigations for this patient?
    Check his medical history (vomiting, diarrhea, and drug intake).
    request VBG(alkalosis or acidosis)
    send urinary for K/cr ratio, Fraction excretion of Mg
    ALT, AST, TSH
    CK
    ECG

  • Ben Lomatayo


    A. Interpret the above laboratory investigation

    • This guy had serious electrolytes disturbances in form of severe hypokalemia, hypomagnesaemia, with normal Pi, Cr, & PTH.

    B. Would you recommend further investigations for this patient?

    Yes, the following investigations are strongly recommended

    • Acid base status: blood PH, bicarbonate, urine PH
    • Anion gap
    • 24h urinary K or spot urine K & spot urine Cr
    • Calculate urine K to urine Cr ratio (K/Cr)
    • Check blood pressure: Normal or low BP & K/Cr > 1 = tubular/renal. If the the BP is high & K/Cr > 1 = mineralocorticoid excess. K/Cr ratio < 1 is favoring extra-renal causes
    • Creatine phosphokinase
    • Thyroid function test
    • ECG
  • Abdulrahman Almutawakel


    THIS PATIENT HAS SEVERE HYPOMAGNESEMIA THEN HE HE HAS HYPOKALEMIA AND HYPOCALCEMIA , IN MY OPINION 1ST WE NEED TO CORRECT THE HYPOAGNESEMIA ( WITH CARDIAC MONITORING ) THEN IF NEEDED CORRECTION OF THE HYPOKALEMIA AND HYPOCALCEMIA , NEEDS FOR FURTHER INVESTIGATION ( ACID BASE STATUS , SEARCHING FOR THE CAUSE OF SEVERE HYPOMAGNESEMIA ( MEDICATION , GI OR RENAL LOSSES )

  • Ashraf Ahmed Mahmoud


    Interpret the above laboratory investigation

    • hypomagnesemia
    • hypokalemia. .
    • hypocalcemia

     Would you recommend further investigations for this patient

    • Review his medication esp ( diuretic –ppi).
    • ask about alcohol drink.
    • urinary Calcium
    • ABG-ECG
    • THYROID function
  • Mahmud ISLAM


    This patient has severe hypomagnesemia and concomitant hypokalemia. Hypokalemia would result or could be pronounced in the presence of hypomagnesemia. Mild hypocalcemia could be because of hypomagnesemia and or vitamin d deficiency.

    We need to investigate urinary potassium and magnesium in excretion in urine
    magnesium should be administered quickly in addition to potassium. The patient should be closely monitored for risk of respiratory arrest
    severe hypokalemia may lead to rambdomyelisis

  • Emad mohamed mokbel Salem


    A-severe hypkalemia ,hypocalcemia ,hypomagnesemia ,elevated PTH (dt low Mg)
    normal creatinine and phosphate

    b- order ECG ,TFT ,CK ,check fraction excretion of Mg,and urinary diurtic screen ask about diuretic use ,ABG

  • Ibrahim Omar


    A. Interpret the above laboratory investigation

    • normal serum creatinine and phosphorus.
    • hypokalemia, hypocalcemia and hypomagnesemia.

    B. Would you recommend further investigations for this patient?

    • yes. ABG or VBG is highly needed.
    • he needs also to check 24 hour urinary calcium, magnesium and potassium to check whether there is renal or GIT losses.

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