A 67-year-old man with CKD presented to the hospital with a history of recurrent syncopal attacks within the past two days. The patient was complaining of chronic constipation, for which he is receiving psyllium 7g daily and magnesium (Mg) oxide 500 mg BID for five months. On examination, the patient was unable to walk due to muscle weakness of both lower limbs. The patient showed mild dysarthria
Review of the patient’s Laboratory investigation revealed:
|
Test |
Value |
|
S. Creatinine |
2.9 mg/dL |
|
S. corrected Calcium |
8.4 mg/dL |
|
S. Phosphorus |
5.2 mg/dL |
|
S. Potassium |
5.1 meq/L |
|
iPTH |
48 pg/mL |
A. Interpret the above investigations.
B. Would you recommend any further investigations?
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A. The patient has renal impairment stage IV, mild hypocalcemia, mild hyperkalemia, hyperphosphatemia.
this is unconcordant with his complaints
B. Investigation to exclude metabolic causes i.e., ABG, Mg, Vit D
neurological causes: EMG, nerve conduction velocity
CKD G4 (eGFR 23), hypocalcemia, hyper-phosphatemia, high normal K,
Would recommend S.Na, S.Mg, RBS, ALP, vitamin D, CT brain, echo
CKD 4 high phosphate low calcium
mg and electrolytes
abg
ct head
liver test
1-CKD stage IV. High normal serum phosphorus and potassium but low normal serum calcium level. PTH level is within normal range.
2-sodium and magnesium level
ABG
liver function test
Brain CT
CKD pt with low normal Ca, high normal K and P
Rest of electrolyte panel
A. Interpret the above investigations.
ESRD patient with high normal K and PH levels, and low normal Ca level.
B. Would you recommend any further investigations?
Check Na, Mg, glucose, and TFT.
If excluded electrolytes, minerals and metabolic derangement, will order brain MRI +/- MRA and EEG.
Model Answer approved by the board:
Interpret the above investigations.
The patient has CKD stage IV. High normal serum phosphorus and potassium but low normal serum calcium level. PTH level is within normal range. These investigations do not explain his recent medical condition, so further investigations are needed.
Would you recommend any further investigations?
This patient presented with muscle weakness and dysarthria that could be caused by many disorders. Other electrolytes should be checked like sodium and magnesium because abnormalities in these electrolytes can cause the patient presentation. Arterial blood gas may help in this case, because both metabolic acidosis or alkalosis can cause muscle weakness. Patients with liver cell failure may present with fatigue, muscle weakness and dysarthria. So, liver function test is to be screened. Volume assessment of the patient is helpful because dehydration can cause this picture.
Brain imaging either CT or MRI , EMG and EEG is of value to exclude any CNS disorders.
A
CKD 4
mild hypocalcemia,
High PO4,
mild hyperkalmia ,
B- complete cns examination
Mg level vbg ecg
ct brain
A
CKD-4, mild hypocalcemia, High PO4, mild hyperkalemia,
B
Mg, TFT, blood gases
A. Interpret the above investigations.
CKD stage 4
mild hypocalcemia
mild hyperphosphatemia
slightly increased k
normalPTH
B. Would you recommend any further investigations?
Patients with symptomatic hypermagnesemia caused by medication.
Serum Mg test
ECG
Electrolytes, LFT, TFT, BGA. 24 hour blood pressure,vit D
Neurological assessment CT ,
CKD stage 4
mild hypocalcemia
mild hyperphosphatemia
slightly increased k
normalPTH
send for s. Mg
CKD stage 4, mild hypocalcemia, serum potassium level (at upper normal),mild hyperphosphatemia,normal PTH
Check serum magnesium level.
Although symptoms are not straightforward and are mixed, there are consistent with hypermagnesemia caused by medication. Neurotransmitter release is disrupted. To confirm this probability, we need to check magnesium levels. Calcium and potassium are reported normal.
Aggravated by advanced CKD where there is defective Mg excretion by renal tubules.
for: Serum Mg level, Complete renal electrolyte panel, ABG
A)case of CKD stage4
B)S.mg
A: Chronic Kidney Disease: Stage 4 with Mild Hyperphosphatemia and lowish PTH
B: Evaluate for the constipation and neurological state
Do a Mg-level
This patient is having hypermagnesemia due to an oral Mg supplement
His Mg level not check but the K on the high side which is reflecting the Mg level .
need to hold oral Mg and then manage accordingly
A.interprrtation of lab
Renal impairment stage IV ckd upper normal of k and po4 normal level ca and pth.
B. Recommended investigation serum mg level, ABG, vit d level , vit b 12other neurological evaluation like CT brain
The above patient develop symptomatic hypermagnesemia as he receives chronic magnesium supplements;
The condition is aggravated by advanced CKD where there is defective Mg excretion by renal tubules.
Further investigation;
A. Interpret the above investigations.
B. Would you recommend any further investigations?
A. CKD, hypocalcemia, hyperphophatemia,
Normo-hyperkalemia.
B. Serum Magnesium, CT to exclude a stroke or metastatic Colon cancer (history of constipation) ,24 hour ECG, BGA.24 hour blood pressure, echocardiography to assess syncope.
A- renal impairment , hypocalcemia , mild hyperkalemia with hyperphosphatemia
B- serum magnesium levels , ECG , TSH , CT brain and colonoscopy
A. CKD with elevated s. Phosphorous, potassium, decrease s. Ca
B. S. Mg, ECG
A. Interpret the above investigations.
CKD, upper normal potassium, low normal calcium , acceptable P.
iPTH below the expected range in relation to the degree of CKD
B. Would you recommend any further investigations?
Serum Magnesium .
A. Interpret the above investigations.
Advanced stage CKD, upper normal potassium, and other electrolytes and iPTH within the expected range in relation to the degree of CKD
B. Would you recommend any further investigations?
He is on magnesium. need to send serum Mg, Na, CK, LFT, TSH, Nerve conduction study, ECG, and CT brain
pt. is CKD c/o constipation
under laxative treatment for 5 M
Presented with syncopal attack , muscle weakness ,and neurological signs ( mild dysarthria )
the lab revealed
normal ca , and PTH
mild increases pi and k
recommendation further investigation
Mg. ABG , liver enzymes ,vit D
Neurological assessment CT ,
A. Interpret the above investigations.
B. Would you recommend any further investigations?
THIS PATIENT HAS CKD STAGE 4 , ALMOST NORMAL CALCIUM AND POTASSIUM NEEDS FOR OTHER ELECTROLYTES SPEICIALY MAGNESIUM , VIT D LEVEL , ALSO NEEDS FOR NEUROLOGICAL EVALUATION MAY NEEDS CT , MRI EMG , NERV STUDY ALSO AS THOSE LAB CAN NOT EXPLAINED THE PATIENT CONDITION
B. Would you recommend any further investigations?
ECG-ABG
CT brain
s.Mg
A-CKD G4 (CKD EPI2021 EGFR 23 ML/MIN)
mild hyperphosphatemia ,hyperkalemia ,,calcium within normal range
low PTH according this stage of CKD
===========
b-
order serum magnesium
ECG ,cbc (to check HB )
TFT
A. Interpret the above investigations.
B. Would you recommend any further investigations?