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HYPOKALEMIA
Case of J. D. R.
Ba utista | Rucio | A dap , Da quina g
OBJECTIVES
OBJECTIVES
CASE OF HYPOKALEMIA
CASE PRESENTATION
To present a case of
hypokalemia
APPROACH
TO
To discuss an
DIAGNOSIS
approach in
diagnosing
hypokalemia
PROGNOSIS
MANAGE
To present the management
for hypokalemia
To discuss the
prognosis of
the case
THE CASE
R. D. C.
30/M
Filipino
Roman Catholic
Single
High
school
graduate
Company worker
Born in Aklan
Currently residing
in
Donggalo,
Paranaque City
Admitted for the 1st
time
Bilateral Leg
Weakness
HISTORY OF PRESENT
Comorbi
2ILLNESS
days
In the
ds
(-) known
thyroid or
kidney
disease
PTA
Weakness of lower
extremities: thighs
> legs
(-) strenuous
activities
(-) binge
eating/drinking
(-) dyspnea, chest
pain
(-) vomiting
(-) headache, loss
of sensation,
dizziness, seizure,
limitation of motion
(-) consult
(-) medications
taken
interim
Progression of
weakness
On the day
of consult
Persistence of
weakness
Inability to
ambulate
MEDICAL HISTORY
Past Medical
History
(-) hypertension, DM
bronchial asthma, liver
disease, cancer
(-) PTB treatment
(-) medications taken
(-) allergy to food and
drugs
(-) previous surgeries
(-) previous
hospitalizations
Family
Medical
(-) neuromuscular
History
disease, hypertension,
DM, stroke, heart
disease
(-) bronchial asthma,
PTB
(-) bleeding diathesis,
cancer
(-) thyroid, liver and
kidney disease
Personal and
Social
Nonsmoker
Occasional alcoholic
beverage drinker, 1-2
bottles/drinking spree,
2x/month
Denies illicit drug use
Company worker
Review
of Systems
SHEENT: No
scars, skin
lesions,
blurring of
vision, hearing
loss, eye/ear
discharge,
tinnitus, neck
mass
Respiratory:
No dyspnea,
cough, colds,
hemoptysis
Cardiovascular
: No chest
pain,
orthopnea,
paroxysmal
nocturnal
dyspnea,
palpitations
GENERAL: No
weight
gain/loss,
fever, loss of
appetite, easy
fatigability
Gastrointestin
al: No
abdominal
pain, changes
in bowel
movement,
melena,
hematochezia,
vomiting,
Genitourinary:
hematemesis
a No dysuria,
nocturia,
polyuria,
frequency,
urgency,
frothy urine,
hematuria
Endocrine: No
polydipsia,
heat and cold
intolerance
Physical Examination
General
Awake
Alert
Coherent
With difficulty
ambulating
Speaks in
sentences
Not in
cardiorespiratory
distress
Vital Signs
BP: 120/80
HR: 71
RR: 20
Temp: 36.2
O2 saturation:
98%
Weight: 62.5 kgs
Height: 165 cm
BMI: 22.96
SHEENT
No skin lesions,
masses
Good skin turgor
Anicteric sclerae
Pink palpebral
conjunctivae
No eye
discharge
No nasoaural
discharge
No
tonsillopharynge
al congestion
Moist oral
mucosa
Physical Examination
Chest and Lungs
Symmetric chest
expansion
No retractions
Bronchovesicular
breath sounds
Heart
Adynamic
precordium
Normal rate
Regular rhythm
Point of maximal
impulse at 5th
ICS left
midclavicular
line
Distinct S1 and
S2
No murmurs
appreciated
Abdomen
Flat
Normoactive
bowel sounds
Soft
Nontender
Physical Examination
Extremities
Neurological
Conversant
Coherent
Oriented to
time, place, and
person
Follows
instructions
Intact recent
and remote
memory
Neurological: Cranial
Nerves
I able to smell coffee
II, III- pupils equally
and briskly reactive to
light and
accommodation (2-3
mm)
III, IV, VI - Extraocular
muscle movements
intact
V- No facial sensory
loss in the forehead,
cheeks, and jaw; brisk
corneal reflex
VII- No facial
asymmetry
VIII - With intact gross
hearing
IX, X- Positive gag
reflex, no deviation of
the uvula
Physical Examination
Neurological: Motor
5/
5
4/
5
3/
5
5/
5
4/
5 5/
5
3/
5
5/
5
Neurological: Sensory
10
0
10
0
10
0
10
0
10
0 10
0
10
0
10
0
Neurological: Reflexes
+
+
+
+
+
+
+
+
+
+ +
+
+
+
+
+
Physical Examination
Neurological: Cerebellar
No dysmetria
No
dysdiadochokines
ia
Neurological: Other
Reflexes
No Babinski
No nuchal
rigidity
SALIENT FEATURES
SALIENT FEATURES
30/M
Bilateral
leg
weakness
2 days history
No known
comorbids
Progressive
weakness:
thighs >>>
legs
No past
medical or
familial
history
No
medication
s taken
No
Strenuous activities
Binge
eating/drinkng
Associated
symptoms
No other
subjective
complaints
Occasional alcoholic
beverage drinker
Denies illicit drug use
Company worker
SALIENT FEATURES
120/80
71
20
36.2
98%
Follows command
Oriented to 3 spheres
Intact memory
No facial asymmetry
No slurring of speech
Good gag
5/
5
5/
5
4/ 4/
5 5
3/ 3/
5 5
5/
5/
In the ER
IN THE ER
S
Assessment
O
A
P
IN THE ER
Diet
and
Fluids
S High potassium, regular diet
O
A
P
IN THE ER
S
O
A
P
Diagnostics
12 LECG
Na, K, Cl
CBC with PC
Urinalysis
BUN, Crea
Chest Xray PA
ABGs
1
2
L
E
C
G
ECG Changes
Flattening of T waves
T wave inversion
ST sagging
Prominent u waves
Prolonged PR interval
Widened QRS complex
Ventricular fibrillation
IN THE ER
S
O
A
P
Diagnostics
12 LECG
Na, K, Cl
CBC with PC
Urinalysis
BUN, Crea
Chest Xray PA
ABGs
BLOOD CHEMISTRY
Paramete
r
BUN
Crea
Na
K
Cl
Normal
05/21
1.7 8.3
89 104
134 -145
3.4 5.0
93 109
4.91
79.63
137.1
1.59
108.4
IN THE ER
S
O
A
P
Diagnostics
12 LECG
Na, K, Cl
CBC with PC
Urinalysis
BUN, Crea
Chest Xray PA
ABGs
Normal
5.2-12.4
40-74
19-48
3.4-9
0-7
0-1.5
4.5-6.2
14-18
42-52
80-94
27-31
33-37
150-450
05/21
13.67
73.7
16.3
7.4
2.5
0.1
5.96
14.4
45.6
76.6
24.1
31.5
488
IN THE ER
S
O
A
P
Diagnostics
12 LECG
Na, K, Cl
CBC with PC
Urinalysis
BUN, Crea
Chest Xray PA
ABGs
URINALYSIS
Parameter
PHYSICAL
Color
Transparency
CHEMICAL
Albumin
Sugar
Specific Gravity
pH
MICROSCOPIC
Epithelial Cell
Mucus Thread
Amorphous Phosphate
WBC
RBC
05/21
Straw
Clear
Trace
Negative
1.010
7.0
Few
Few
Few
1-2
0-1
IN THE ER
S
O
A
P
Diagnostics
12 LECG
Na, K, Cl
CBC with PC
Urinalysis
BUN, Crea
Chest Xray PA
ABGs
CHEST XRAY
Move to
Therapy
YES
Emergency
NO
Treat according
and reevaluate
K
Hypokalemi
a
Serum K+ <3.5
mmol/L
3.4 5.0
Treat
accordingly
1.59
YES
YES
Clear evidence
of low intake
No further
Insulin excess
workup
Beta-adrenergic
agonists
YES
FHPP
Pseudohypokale
Hyperthyroidism
mia
Barium intoxication
Theophylline
NO
Chloroquine
Clear evidence
of intracellular
shift
Factors Affecting
Distribution of Potassium
between Intracellular and
Extracellular
Compartments
Consequences of
Excitable Muscles Hypokalemia
Renal
Cardiovascular
Risk factor for both
ventricular and atrial
arrhythmia
Impaired muscle
contraction
Proximal tubular
vacuolization
Interstitial nephritis
Renal cysts
ESRD
Acute renal failure with
proximal tubular
vacuolopathy
Worsening of hypertension,
heart failure, and stroke
Reduction of insulin
secretion
IN THE ER
S
O
A
P
Diagnostics
12 LECG
Na, K, Cl
CBC with PC
Urinalysis
BUN, Crea
Chest Xray PA
ABGs
Normal
05/21
7.35-7.45
35-45
22-26
7.364
31
108
13.4
-11
96.9
12.2
15.1
IN THE ER
Diet
and
Fluids
S High potassium, regular diet
O
A
P
IN THE ER
S
Medications
O
A
P
IN THE ER
Supplementary
S Hook to cardiac monitor if available; if not, do daily 12
O
A
P
LECG
Moderate to high back rest
Strict I and O monitoring
WOF: weakness, dyspnea, chest pain, changes in
sensorium, and hypertension
VSQ1
COURSE IN THE
WARDS
S
O
A
P
Subjective
Objective
110/70, 78, 20, 36.1
No dyspnea
No chest pain
No abdominal pain
No cramps
Progression of
weakness
5/
5
5/
5
2/
5
4/
5
5/
5 5/
5
2/
5
4/
5
On the 1 hospital
day
Assessment Plan
st
O
A
P
Hypokalemia
etiology to be
determined
PTB Suspect
High K diet
IVF: PNSS 1L + 40 mEqs KCl x 125
cc/hr
Other diagnostics facilitated
Medications:
KCl tab 1 tab TID
Management continued
On the 2
S
O
A
P
nd
hospital day
Subjective
Objective
110/60, 66, 19 , 36.1
No dyspnea
No chest pain
No abdominal pain
No cramps
Progression of
weakness
5/
5
5/
5
2/
5
2/
5
5/
5 5/
5
2/
5
2/
5
BLOOD CHEMISTRY
Paramet
er
K
Normal
05/21
05/22
3.4 5.0
1.59
2.13
KUB ULTRASOUND
The right kidney measures 10.3 x 5.8 x 5.1 cmn with cortical thickness of 0.8 cm and the
left kidney measures 11.0 x 5.0 x 4.5 cm with cortical thickness of 1.0 cm. the cortices
are intact. The medullary pyramids are markedly echogenic, bilaterally. A 1.2 cm cyst is
seen in the right midportion. Two cysts measuring 1.1 cm and 0.4 cm are also noted in
the right midportion. Two hypoechoic foci with high intensity echoes (measuring 0.5 cm
and 0.3 cm) within are also seen in the left superior pole. The pelvocalyces are mildly
dilated, bilaterally.
The urinary bladder is smooth in outline. Wall is not thickened. There are no abnormal
intraluminal echoes.
On the 2 hospital
day
Assessment Plan
nd
O
A
P
Hypokalemia
etiology to be
determined
PTB Suspect
High K diet
IVF: PNSS 1L + 40 mEqs KCl x 125
cc/hr
Other diagnostics facilitated
Medications:
KCl tab 1 tab TID
Management continued
S
O
A
P
Subjective
Objective
110/70, 80, 19, 37
No dyspnea
No chest pain
No abdominal pain
No cramps
Decreased
weakness
5/
5
5/
5
4/
5
4/
5
5/
5 5/
5
4/
5
4/
5
BLOOD CHEMISTRY
Parame
ter
K
Normal
05/23
3.4 5.0
3.35
URINE ELECTROLYTES
Parameters
Creatinine
Sodium
Potassium
Normal
Values
5/23
100-200
40-220
25-125
36.39
41.9
9.2
Move to
Therapy
YES
Emergency
NO
No further
workup
Hypokalemi
a
Serum K+ <3.5
mmol/L
NO
YES
YES
NO
Pseudohypokale
mia
Treat
accordingly
Treat according
and reevaluate
Clear evidence
of low intake
YES
Clear evidence
of intracellular
shift
NO
Normal
Parameters
Values
Urine
K
100-200
Creatinine
mg/dL
25-125
Potassium
<15 mmol/day
mmol/L
5/23
36.39
9.2
OR <15 mmol/g
Cr
>15 mmol/day
OR >15 mmol/g
Cr
Urine K
<15 mmol/day
OR <15 mmol/g
Cr
Extrarenal loss/
remote renal
loss
Acid-base
status
>15 mmol/day
OR >15 mmol/g
Cr
Metabolic
Alkalosis
Metabolic
acidosis
GI K+ loss
Normal
Profuse
sweating
Remote
diuretic use
Remote
vomiting or
stomach
drainage
Profuse
sweating
Urine K
<15 mmol/day
OR <15 mmol/g
Cr
>15 mmol/day
OR >15 mmol/g
Cr
Extrarenal loss/
remote renal
loss
Renal loss
Acid-base
status
TTKG
Osmolurine = (Urine SG 1) x
40000
= (1.010 1) x 40000
= 400
>4
distal
secretion
Low OR normal
<2
BP and/or
Volume
tubular flow
Osmotic
diuresis
High
Aldosterone
High
Low
Renin
Cortisol
High
RAS
RST
Malignant
HPN
Low
PA
FH-I
High
Normal
Cushings
Syndrome
Liddles
syndrome
Licorice
SAME
>4
distal
secretion
Low OR normal
<2
BP and/or
Volume
tubular flow
Osmotic
diuresis
High
Acid-Base
status
Parame
ter
pH
pCO2
pO2
HCO3
BE
O2St
TCO2
SBc
Normal
05/21
7.35-7.45
35-45
22-26
7.364
31
108
13.4
-11
96.9
12.2
15.1
Variable
Acid-Base
status
Nonreabsorbable
anions other
than HCO3Hippurate
Penicillins
Metabolic
Acidosis
Metabolic
Alkalosis
Urine Cl(mmol/L)
>20
<10
Urine Ca/Cr
(molar ratio)
Vomiting
Chloride
Diarrhea
>0.20
<0.15
Loop diuretic
Bartters
syndrome
Thiazide
diuretic
Gitelmans
syndrome
Variable
Acid-Base
status
Nonreabsorbable
anions other
than HCO3Hippurate
Penicillins
Metabolic
Acidosis
Metabolic
Alkalosis
Proximal RTA
Distal RTA
DKA
Ampothericin B
Acetazolamide
Urine Cl(mmol/L)
On the 3 hospital
day
Assessment Plan
rd
O
A
P
Hypokalemia
etiology to be
determined
t/c RTA
PTB Suspect
High K diet
Shift IVF to heplock
Other diagnostics facilitated
Medications:
KCl tab 1 tab TID
Management continued
S
O
A
P
Subjective
Objective
90/60, 60, 19, 36.1
No dyspnea
No chest pain
No abdominal pain
No cramps
Progression of
weakness
5/
5
5/
5
5/
5
5/
5
5/
5 5/
5
5/
5
5/
5
On the 4 hospital
day
Assessment Plan
th
O
A
P
Hypokalemia
etiology to be
determined
t/c RTA
PTB Suspect
High K diet
Heplock
Other diagnostics facilitated
Medications:
KCl tab 1 tab TID
Management continued
S
O
A
P
Subjective
Objective
110/70, 66, 19, 37,
No dyspnea
No chest pain
No abdominal pain
No body weakness
98%
Awake, alert, not in
distress
Moist mucosae
With bronchovesicular
breath sounds
Adynamic precordium,
no murmurs
No edema
5/
5
5/
5
5/
5
5/
5
5/
5 5/
5
5/
5
5/
5
On the 5 hospital
day
AssessmentMay go home orders
th
O
A
P
Hypokalemia
etiology to be
determined
t/c RTA
PTB Suspect
Diagnostics:
FT4, TSH
Urine Calcium, phosphorus
DSSM x 2
Medications:
Potassium Citrate 1 tab 3 x a day
PLAN and
PROGNOSIS
PLAN and
PROGNOSIS