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58 year old lady: No known co-morbidities, C

HOPC: Apparently well till one week back, when she developed spasm of both hands. Insidious in onset, more towards evening, relieved on its own or by message, but recur. No weakness of hands/legs. Tingling sensation of palm and soles- 1 day, present around the mouth also. . 9/08/20

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58 year old lady: No known co-morbidities, C

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    3. Past Hx: Back pain- 4-5 years, under orthopedic evaluation-? Osteoporosis Weight loss- could not quantify. Cataract Sx- 1 year back.

    4. Personal Hx: Decreased sleep/ Appetite. Bowel and Bladder- N Menopause- 20 yrs back Family history/ Drug history: Nothing significant.

    5. GPE: Conscious, oriented, depressed looking Moderately built, poorly nourished PR:78bpm, regular. Peripheral pulses + RR: 16/min. BP: 122/80mmHg, Afebrile Pallor (+) No Ict/LNE/Club/Cyan/Edema

    6. Systemic examination: RS: Trachea: Central. NVBS, No rhonchi/crepts CVS: S1, S2 heard, No murmurs PA: Soft/ No Organomegaly, BS(+) CNS: HMF:N, CN:N, Power, Tone: N, Sensory:N, DTR:B/L N, Plantars: B/L: Flexor, Cerebellar Signs: None, Skull & Spine:N, No neck stiffness.

    7. Local examination: Flexion at the wrist, MCP joints and extension of the interphalangeal joints Chvostek sign: Positive Trousseaus sign: Positive

    8. Impression : ? Hypocalcemia ? Cause

    10. Impression : Hypocalcemia ? Cause

    11. Investigation reports: Hb %- 11.6gm/dl TC: 10.3 N/L: 74/18, ESR: 62 LFT: Raised ALP: 248.6 Alb: 3.8, Glo: 3.9, Renal Function: Urea:22.3, Creat: 0.58 S. Electrolytes: Na- 142, K- 3.3mmol/L, Ca: 5.8, Mg- 1.6, PO4- 2.4 mg/dl Trop- I 0.011ng/ml, CK-MB- 12.3 IU/L CXR: Osteoporotic picture

    12. Admitted to Annexe MICU, IV 10% Ca.gluconate 10ml over 10 mins Oral supplementation of Ca. KCl.

    13. Ca now dropped to 7.4. BP: 110/90 mm Hg Systems: Status quo IV Ca correction continued

    14. Sudden jerky movements of head, uprolling of eyes, sweating, vomiting, unresponsiveness lasting appx for 1 min. BP: 100/60mmHg, PR: 76/min Saturation: 70%, GRBS: 169. High flow Oxygen, Head end ?

    15. Episodes of Vomiting- sweating- uprolling of eyes- unresponsiveness- fall in BP- Bradycardia Tachycardia- High BP continues.

    19. Pt put on Dopamine Trop I 0.033ng/ml ECGs taken to cardiologist, does not suspect a cardiac pathology. ? Vagal. Endocrine consult: Vit D deficiency- Nutritional with secondary hyperparathyroidism Adv: Calcitriol oral

    21. Serum calcium levels continued to be in the range of 6.9- 7.0. Hence IV Correction was continued along with Calcitriol supplementation Correction of Mg by IV infusion, Potassium correction orally. No further episodes of tachy/ brady phenomenon. Echo : Normal

    22. Urine culture showed significant growth of Klebsiella pneumoniae. Hence treated with inj. Ceftraxone for 7 days. 25 OH D3 level: 15.9 (?)

    23. At the time of discharge, the calcium level was 8.8. Symptomatically better. Advised to come to OPD for further evaluation of hypocalcemia. Diagnosis: Hypocalcemia under evaluation Osteoporosis UTI- Klebsiella Pneumoniae.

    24. HYPOCALCEMIA Normal : 8.5 to10.5 mg/dl Appx 50% is bound to negatively charged proteins, predominantly albumin Normal dietary intake: 400- 1500 mg/d Daily net absorption: 200- 400 mg/d 150- 300 mg is excreted by kidneys.

    25. D/D for hypocalcemia Hypoalbuminemia (cirrhosis, nephrosis, malnutrition, burns, chronic illness, and sepsis). Vitamin D deficiency Alkalosis: Hyperventillation, conns syndrome Chronic Renal failure Hypoparathyroidism- Congenital/ post surgical Pseudo hypoparathyroidism Acute Pancreatitis Malignancy: Osteoblastic lesions

    26. D/d for prolonged QT interval Congenital: Congenital QT prolongation Mitral Valve prolapse syndrome Acquired: Electrolytes: Hypocalcemia/Hypomagnesemia Drugs: Quinidine, Amiodarone MI, Viral myocarditis, Rheumatic fever, Head injury, Haemorrhage, A-V block, Sinus bradycardia

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