A 65-year-old-male with a history of cerebrovascular accident from 2 weeks was referred to our hospital with the complaints of diminished appetite and drowsiness since last night. He is a smoker since past 30 years. He had no history of hypertension and diabetes mellitus. On examination, his blood pressure was 140/40 mmHg, pulse was irregular and the rate was 52/min, SPO2 98% with O2. On cardiac auscultation, s1 and s2 were clear and audible.
On admission, patients electrocardiogram demonstrated irregular rhythms with right bundle branch block and left axis deviation (figure 1).
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| Figure 1 |
Laboratory results showed pH 7.43, hemoglobin 9.2 gm%, total leucocyte count 19800/mcL, serum K+ 7.5 mEq/L, serum urea 176 mg/dl, serum creatinine 3.6 mg/dl while his liver function tests were normal. Patient’s chest radiograph showed bilateral bronchopneumonia (figure 2).
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| Figure 2 |
Echocardiography showed concentric left ventricular hypertrophy with the ejection fraction of 60%. The patient was immediately given Inj. calcium gluconate and started on 25% dextrose saline combined with 10 units’ human insulin intravenously. Azithromycin was continued empirically along with other supportive management. On the same day around 8 PM serum K+ level came down to 6.8 mEq/L and his repeat electrocardiogram showed a sinus rhythm (figure 3).
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| Figure 3 |
Management of hyperkalemia was continued and subsequent measurements showed improvement in serum K+ levels from 6.1 mEq/L (2nd day), 4.9 mEq/L (3rd day), 4.6 mEq/L (4th day), to 4.4 mEq/L (5th day) and repeat electrocardiogram showed sinus rhythm (figure 4).
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| Figure 4 |
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