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Hi Ali These are some of her spot urine results, bear in mind that she takes slow-K two tablets bd. 24hr urine mets were normal though the 24hr urine volume is not convincing- I might repeat that again. Potassium [Urine] 166.8 mmol/L ~~~~~~~~~~~~~~~~~ Chloride [Urine] 114 mmol/L ~~~~~~~~~~~~~~~~~ Creatinine [Urine] 18.31 mmol/L Magnesium [Urine] 3.32 mmol/L Creatinine [Urine] 18.28 mmol/L Magnesium creatinine ratio [Urine] 0.18 mmol/mmol Calcium [Urine] 1.57 mmol/L Creatinine [Urine] 18.42 mmol/L Calcium:creatinine ratio [urine] 0.09 mmol/mmol <0.75 pH [Urine] #~ 5.7 Urine volume (ml) 553 ml Urine collection period 24.0 Hrs Normetadrenaline [Urine] 1.49 umol/L Normetadrenaline output [24hr urine] 0.82 umol/24h <4.00 Metadrenaline [Urine] 0.84 umol/L Metadrenaline output [24hr urine] 0.46 umol/24h <2.00 -----Original Message----- From: Al-Bahrani Ali [mailto:[log in to unmask]] Sent: 13 September 2016 12:37 To: Soha Zouwail (Cardiff and Vale UHB - Medical Biochemistry); [log in to unmask] Subject: RE: Hypokalaemia The pattern is in keeping with hyperchloraemic normal anion gap compensated metabolic acidosis, I wonder if she has renal tubular or lower GI trouble, if so where do you stand on this! Any urine work up please! Kind Regards ALi Dr Ali Al-bahrani MBCh.B MSc.Chem Path. EuClin.chem. CSci. FRCPath. Lead Pathologist for Blood Sciences RCPath Wessex Professionalism Lead Consultant Chemical Pathologist and metabolic medicine and HOD of Blood Sciences St Mary's Hospital Newport Isle of Wight PO30 5TG United Kingdom Te: 01983 534859/534917 -----Original Message----- From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Soha Zouwail (Cardiff and Vale UHB - Medical Biochemistry) Sent: 13 September 2016 12:08 To: [log in to unmask] Subject: Re: Hypokalaemia Hi Mohammed Thank you for your reply. 24hr urine mets were done for her and they were within normal limits. I agree with you that this is all due to increased adrenergic stimulation but I can't find why? Patient denied any illicit drugs but I can ask the question again. BW Soha -----Original Message----- From: Mohammad Al-Jubouri [mailto:[log in to unmask]] Sent: 13 September 2016 11:55 To: Soha Zouwail (Cardiff and Vale UHB - Medical Biochemistry) Cc: [log in to unmask] Subject: Re: Hypokalaemia There is evidence of episodic increased adrenergic stimulation causing tachycardia, sweating, intracellular shift of potassium leading to hypokalaemia, hyperglycaemia and hyperlactataemia. This could be due to endogenous catecholamines release like in phaeochromocytoma or due to use of cocaine or cocaine like substance causing a state similar to periodic hypokalaemia paralysis. I would suggest measuring plasma free metanephrines or urinary free catecholamines and drug of abuse screen. Best regards Mohammad > On 13 Sep 2016, at 11:36, Soha Zouwail (Cardiff and Vale UHB - Medical Biochemistry) <[log in to unmask]> wrote: > > Hi Ali > Nice to hear from you as well. This is her ABG from the last admission, she felt feverish with loin pain ?UTI and she was started on antibiotics. Mg was 0.58 mmol/L, sinus tachycardia, breathlessness and chest pain. Forgot to mention that these episodes usually associated with syncope. > > pH [POCT] 7.37 > pCO2 [POCT] 3.93 kPa > pO2 [POCT] 17.20 kPa > Base excess [POCT] -7.8 mmol/L > Base excess ecf [POCT] -7.8 mmol/L > Total Hb (calculated) [POCT] 133.0 g/L > Carboxyhaemoglobin [POCT] 0.8 % <2.0 > Methaemoglobin [POCT] 1.2 % <1.5 > Sodium [POCT] 140 mmol/L 133-146 > Potassium [POCT] 2.5 mmol/L * 3.5-5.0 > Chloride [POCT] 109 mmol/L * 95-108 > Calcium (ionised) [POCT] 1.20 mmol/L 1.15-1.30 > Glucose [POCT] 17.8 mmol/L * 2.8-12.0 > Lactate [POCT] 6.0 mmol/L * 0.5-1.6 > > -----Original Message----- > From: Al-Bahrani Ali [mailto:[log in to unmask]] > Sent: 13 September 2016 11:31 > To: Soha Zouwail (Cardiff and Vale UHB - Medical Biochemistry); > [log in to unmask] > Subject: RE: Hypokalaemia > > Dear Soha > > Great to hear from, I hope you are doing well! > > What was the pattern of Electrolyte while hypokalaemic was it Hypokalaemia alkalosis or hypercholaermic normal anion gap metabolic acidosis with hypokalaemia. > > > > Kind Regards > > ALi > > Dr Ali Al-bahrani MBCh.B MSc.Chem Path. EuClin.chem. CSci. FRCPath. > Lead Pathologist for Blood Sciences > RCPath Wessex Professionalism Lead > Consultant Chemical Pathologist and metabolic medicine and HOD of > Blood Sciences St Mary's Hospital Newport Isle of Wight PO30 5TG > United Kingdom > Te: 01983 534859/534917 > > > > > > Kind Regards > > ALi > > Dr Ali Al-bahrani MBCh.B MSc.Chem Path. EuClin.chem. CSci. FRCPath. > Lead Pathologist for Blood Sciences > RCPath Wessex Professionalism Lead > Consultant Chemical Pathologist and metabolic medicine and HOD of > Blood Sciences St Mary's Hospital Newport Isle of Wight PO30 5TG > United Kingdom > Te: 01983 534859/534917 > > > > -----Original Message----- > From: Clinical biochemistry discussion list > [mailto:[log in to unmask]] On Behalf Of > [log in to unmask] > Sent: 13 September 2016 11:02 > To: [log in to unmask] > Subject: Hypokalaemia > > Dear all > I wonder if I can pick your brain regarding this patient A 26 year old > lady who experienced recurrent episodes of "weakness and excessive > tiredness" while she was in High School that resulted in many days of > abscences and family attributed that to depression but she had never > sought any medical medical help. These episodes meant that she could > not maintain a job as she was constantly feeling tired. She is > fostered with no information about family history other than a brother > who suffers from epilepsy. > > She has moved area and was later diagnosed with fibromyalgia. She > experiences a constant feeling of palpitations and had several A&E > attendances with these symptoms heart rate 140 bpm, hypokalaemia > 2.5mmol/L, lactic acidosis, sometimes hypoMg, breathlessness and > sweating . > > She was diagnosed with inappropraite sinus tachycardia. 24hr heart > rate was 115 bpm with a range of 90-160. Beta blockers and ablation > had no effect on her heart rate. Thyroid function is normal and in > between these episodes her bloods including K are all normal. No renal > K wasting was found. These episodes can happen at any time and there > is no definite precipitating factor. She said that she started to > experience constant weakness in her left arm with weak grip and is waiting for an > EMG. Genetics (CACNA1S and SCN4A) have excluded Hypokalaemic periodic > paralysis, Conn's have been excluded as well. She has a right kidney > stone. > > Do you think that the HypoK is secondary to the sustained tachycardia? > If that is the case why would her potassium be normal in between the > episodes if she experiences constant tachycardia ? > Any other investigations that should be done in this case? > > Many thanks for your help in revealing the mystery of this case. > > BW > Soha > > ------ACB discussion List Information-------- This is an open > discussion list for the academic and clinical community working in > clinical biochemistry. > Please note, archived messages are public and can be viewed via the > internet. 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