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?
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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
Hypomagnesemia associated with hypokalemia and hypo-calcemia
Further investigations: ECG, VBG, FEMg, UCa/Cr ratio
hypokalaemia and hypomagnesemia causing muscle weakness
low mg can impairment na/k/atpase leading to decrease k
fractional excretion of mg and k
1- hypokalemia with hypomagnesemia
2- need 24 hours mg and creatinine
hypoklemia and hypomagnesemia
yes i would recommend to test tsh, 24 hrs urinary magnesium.
ecg
Severe hypomagnesemia and hypokalemia
24hr urinary mg and creatinine
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
A- ⬇️. K and mg
B- history focuses loss mg and k
check excration ca + mg from kidney 24 hours
TFT
VBG
ECG
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.
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
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
Interpretation :
– hypokalemia and hypomagnesemia
– normal po4 and PTH and renal function
Further investigation:
– medication history
– TSH
– 24 hr urine ca and mg
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.
A)case of hypo mg, hypo k and hypo ca
B)full history and renal excretion of mg and k
A: Hypomagnesemia and Hypokalemia
B: Do a 24hr urine collection for Mg and Creatinine
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
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
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
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
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
A. Hypomagnesemia, hypocalcemia, hypokalemia
B. 24 hours Urin for magnesium, potassium, and calcium
a BGA to exclude RTA.
Medical history
A. Interpret the above laboratory investigation:
*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).
Renal magnesium excretion should be reduced in patients with plasma magnesium depletion.
So:
The interpretation
This hypomagnesemia induces severe symptomatic hypokalemia
Recommended investigation
Complete renal electrolytes panel.
A- a case of hypocalcemia , hypokalemia and hypomagnesemia
B- 24 hour urinary calcium to exclude familial hypomagnesemia with hypercalciuria
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
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 .
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
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
A. Interpret the above laboratory investigation
B. Would you recommend further investigations for this patient?
Yes, the following investigations are strongly recommended
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 )
Interpret the above laboratory investigation
Would you recommend further investigations for this patient
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
Great plan Dr. Mahmud
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
Nice plan Dr. Emad. But iPTH in this scenario is still within the normal range (up to 65)
A. Interpret the above laboratory investigation
B. Would you recommend further investigations for this patient?
Agree