Triage: Lethargic and off balance worsening for a few days.  Responding to external stimuli. Psych history on multiple meds

History of Present Illness: A woman in her early 20’s for generalized weakness and possible increase in auditory hallucinations over the last few days. She recently moved from inpatient resident outpatient but is closely supervised still notes no significant chance she got into any drugs and she has not been feeling suicidal. Patient denies increased hallucinations but staff said they have seen her laughing for no reason and staring off into space so they feel like she is hallucinating. No fever or chills. She has been sleepier than normal having trouble walking a little bit peeing on the toilet and denying it was her just amine urine stream poorly and that they had to clean up after her.

Vital Signs: T: 36.3 °C,   HR: 98,  RR: 16,   BP: 104/72,   SpO2: 100%

Physical Exam: GENERAL: Sleepy but easily awoken and does stay awake but talks in a super soft voice despite prompting to talk more loudly and she is quite difficult to understand
°NEUROLOGIC: Repetitively consistently very soft speech. No focal weakness. Alert and oriented. Mild asterixis

An ECG is done:

 

Computer Read: ST at 104, NSTWA

What is the most likely cause of ECG findings in this patient?

  • A) ACS
  • B) Hypokalemia
  • C) PE
  • D) Drug effect
  • E) None of the above

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

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ANSWER:

  • A) ACS
  • B) Hypokalemia
  • C) PE
  • D) Drug effect
  • E) None of the above

My Read:

CASE CONCLUSION:

  • Serial levels, valproic (therapeutic 50-100): 162, 140, 125, 100
  • Serial levels, ammonia (normal <38) : 21, 68, 56, 45

 

 

 

Case lessons:

  2. ST depression and QT prolongation can both be caused by either high or low potassium, which is definitely unfair.
  3. With high potassium the ST depression is usually flat and the QT prolongation is due to a long, flat ST segment as in this case.  Also the T wave is usually on the narrow side.  In this patient T waves were short but still narrow/spiky.