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Quiz: What Is Your Diagnosis?
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Bahriye Bahar Yücel, Dilek Toprak

A 25 years old woman presented to the emergency department with complaints of numbness and muscle contractions in her hands. Her initial examination revealed hypocalcemia (Ca=7.7 mg/dL) and hypokalemia (K=2.7 mg/dL) so, she was treated  with potassium and calcium supplements. The patient’s control biochemistry results showed the continued hypocalcemia and hypokalemia. The physical examination revealed blood pressure of 110/70 mmHg, pulse 72/min, respiratory rate of 20/min, the existence of numbness in both hands and arms and spasm in hands. Chovestek and Trousseau signs were positive and other system examinations were unremarkable. Hemogram was normal; according to the biochemistry results, her blood urea nitrogen was (BUN) 20 mg/dL, creatinine 0.6 mg/dL, sodium 143 mmol/L, potassium 3.1 mmol/L, chloride 96 mmol/L, 8.1 mg calcium/dL, magnesium 0.8 mg/dL. 

Urine analysis results were normal. Her 24 hour urine test results were as follows; sodium 285.66 mmol/day, potassium 45.202 mmol/day, chlorine 270.204 mmol/day, calcium 23.3 mg/day,  phosphorus 256.3 mg/day and  magnesium 19.596 mg/day.  

Venous blood gas analysis results were as following; pH: 7.428, partial pressure of oxygen (PO2): 29 mmHg, carbon monoxide partial pressure (pCO2): 48.3 mmHg, bicarbonate (HCO3): 31.3 mmol/L, and oxygen saturation (SaO2): 52% which was thought as metabolic alcalosis. Patient’s  thyroid stimulating hormone (TSH), free T4, free T3, parathyroid hormone (PTH) and serum basal cortisol levels were normal. 

In abdominal ultrasonography, a double collecting system view of the left kidney was observed, but no nephrolithiasis or ectasia was detected. 

Her electrocardiogram showed normal sinus rhythm and normal QT interval. Her plasma renin activity (132 ng/L), and aldosterone level (334 pg/ml) was measured while she was lying. There was no medication usage history such as diuretics and laxatives.

QUESTION

What is your diagnosis based on the patient's symptoms and history?
A. Bulimia nervosa
B. Gitelman syndrome
C. The use of diuretics (addiction)
D. Bartter syndrome
E. Excessive use of laxatives drugs


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