Free Web NovelChapter 1108: Chapter 1108: Severe Hypokalemia
Liu Banxia’s question came a bit out of the blue, but the expression on his face was very serious, not like he was joking at all, which made the nurse next to him a little surprised.
But while everyone was still surprised, the patient actually nodded. "I do have hyperthyroidism. Doctor, how did you know?"
"I just noticed your eyeballs are a bit protruding. Besides some basic physiological reasons, that’s most commonly caused by hyperthyroidism. How long has it been since you were diagnosed? Are you on medication?" Liu Banxia asked.
"It’s been a little over four years, I think. But it’s basically fine now. I take medicine every day, it’s under control already. Otherwise I wouldn’t be able to go out with friends so often. This illness isn’t a problem," the patient said.
"Whether it’s a problem or not, you have to let us be the ones to decide. I just asked you and you wouldn’t say anything," Liu Yiqing said, a bit anxious.
"This is also considered an underlying disease? Isn’t it only heart disease, hypertension, and diabetes that count as underlying diseases?" the patient shot back.
"Don’t worry about that for now. Have you had your thyroid checked recently? What medication are you taking?" Liu Banxia asked.
"I’m so flustered I can’t remember. Is this muscle weakness of mine caused by hyperthyroidism?" the patient asked again.
"Methimazole or propylthiouracil?" Liu Banxia asked.
"Right, the first one. I usually just call it ’bazole’, I got nervous and couldn’t remember the generic name," the patient said.
"In your case, these symptoms really could be caused by hyperthyroidism," Liu Banxia said.
"Hyperthyroidism isn’t just eating a lot, getting hungry fast, being afraid of heat, sweating easily, and hand tremors. Some patients also have palpitations, anxiety, emotional excitability, and generalized fatigue."
"And treating hyperthyroidism has to be paired with periodic testing, and then we adjust the dosage based on thyroid hormone levels. Too much is bad, too little doesn’t work."
"When we draw blood, we’ll also check thyroid function, blood biochemistry, serum potassium, liver and kidney function, and then do an ECG. The thyroid secretes endocrine hormones—if it’s oversecreting, it can easily cause endocrine system disorders."
The patient nodded. "Now that you say that, I do kind of feel like my heart is beating a bit fast."
The people around couldn’t help but laugh. That was probably just him being scared.
Still, they were impressed: even though Director Liu had made a mess of things yesterday, his observation and judgment were still sharp. He’d zeroed in on it just by asking one more question after noticing the exophthalmos.
Everyone had seen it, but nobody else had thought anything of it.
After the blood draw they went straight for the ECG, and that was when things blew up. Liu Yiqing suddenly tensed up. "Teacher Liu, the P–R interval is prolonged, and the Q–T interval is significantly prolonged."
Hearing her report, Liu Banxia, who hadn’t been too concerned a moment ago, instantly got nervous as well.
This was a very dangerous ECG pattern. If things went wrong, something big could happen—there was definitely a cardiac issue.
"Doctor, what’s wrong with me?" Seeing Liu Banxia come over to look at the ECG too, the patient grew nervous.
"Try not to panic, just lie down first," Liu Banxia said.
"Notify the lab and mark his blood tests as urgent. Then call an ICU doctor over for a consult, and make it quick. Your condition is indeed a bit critical right now. There’s a minor problem with your heart. Give us a contact number for one of your family members."
That was all Liu Banxia could say for the moment; he couldn’t make it sound too serious for fear of frightening the patient.
The really scary thing on the ECG was the markedly prolonged Q–T interval. That pattern is truly dangerous, because ventricular fibrillation can occur at any time.
It was just like that patient they’d seen a few days ago who was hit in the chest by a ball—his ECG at the time had shown the same pattern. Only in his case it was due to an arteriovenous malformation, while this patient’s was being influenced by some underlying disease.
Considering that this patient had hyperthyroidism, it was very likely that the endocrine disturbance was affecting his potassium ions.
When serum potassium gets too low, it can cause generalized fatigue and muscle weakness.
The key point is that it doesn’t just affect skeletal muscles; it also reduces myocardial contractility and can cause a whole series of cardiac problems, ventricular fibrillation being just one of them.
At first he had thought it was just the muscle weakness that can show up after hyperthyroidism, basically a problem with the patient’s medication regimen. Run some tests, adjust the dosage, and that would be that.
But once this kind of ECG shows up, you don’t dare be careless.
Potassium supplementation isn’t something you can just do casually either. If you replace it too fast or too much, serum potassium will shoot too high and the patient can die from that as well. This calls for someone experienced—namely, an ICU doctor.
"Director Liu, what’s the situation?" ICU doctor Zhang Zhiyuan arrived quickly.
The emergency department usually didn’t call ICU for a consult lightly. If ICU was called, it meant the situation was never minor.
Liu Banxia gave a brief rundown of the patient’s case, and Zhang Zhiyuan picked up the ECG and studied it carefully.
"Dr. Zhang, do you think this could be a thyroid storm?" Liu Banxia asked.
"Not very likely," Zhang Zhiyuan said.
"There’s always some kind of trigger for thyroid storm, like post‑op or an infection. Right now this patient’s vitals are very stable, no fever, no sweating, and the heart rate is only 90."
"I’m basically thinking the same as you, that the patient’s problem is likely hypokalemia. But we don’t have the serum potassium yet, so we can’t give too much. We can start with a small dose of potassium, just in case something dangerous happens."
"But with this ECG, keep the resuscitation equipment ready at the bedside. If something really does go wrong, we can at least start resuscitation."
"Haven’t seen any family around, have you? For all we know we might be issuing a critical condition notice soon, and he’ll probably have to be transferred to our unit. People these days really don’t care much about their own diseases."
That last sentence, of course, was referring to the patient not monitoring his thyroid function.
Hyperthyroidism really is a very complicated disease; if you want a cure you basically need surgery. But after surgery you’re removing an endocrine gland, which is still going to affect the body.
Even though Tang Feifei’s recovery is pretty good now, she still needs regular check‑ups; that’s a hard order from Liu Banxia.
This patient’s disease course is so long, and he just thought taking medicine on his own was enough, which is definitely not the case.
With all these mutual influences, the meds that used to keep it under control may not work in some time windows.
"We’ll get everything ready on our side and wait for the potassium result. Start an IV infusion first; once the result’s back, then you act. If there’s nothing else, just wait here a bit, it’s already been marked urgent," Liu Banxia said.
Zhang Zhiyuan nodded. "Try your best to contact the family. Just from this ECG plus his current presentation, I’m afraid the hypokalemia is already very severe."
This was his judgment based on years of working in the ICU.
Liu Banxia nodded and had Liu Yiqing go explain the situation to the patient, keep it as measured as possible, but the family needed to be notified.
"Teacher Liu, would this count as a misdiagnosis on my part?" After coming back, Liu Yiqing asked cautiously.
"How is this a misdiagnosis? The two things aren’t even remotely related," Liu Banxia said.
"All it shows is that the patient overthought things. You did ask. Even if he didn’t see it as a chronic condition, he should still talk about his past history and medications."
"I only casually asked just now, I never imagined his condition would be this serious. Don’t overthink it, it’s not on you. Just treat him patiently."
Liu Banxia nodded, though he still didn’t look very energetic.
"What’s wrong?" Zhang Zhiyuan asked, curious.
"When the patient was first brought in, she asked too, but she didn’t specifically ask about hyperthyroidism, so the patient didn’t pay attention and didn’t mention it," Liu Banxia said.
"Later I asked one more question, and only then did the patient tell us. Then we added an ECG, and that’s when we saw the major problem. The girl’s blaming herself, she’s a bit worried."
"Even when patients come in by ambulance, we can’t just hook them up to an ECG right away during the physical exam, or immediately start palpating the thyroid size."
"And the way she managed this case was completely within standards; she just over‑interpreted a bit. Once you’ve seen enough patients, you really do run into every kind of situation."
"It’s also just a coincidence. A few days ago when she was on call in the OR, she diagnosed a patient with acute abdominal pain as appendicitis, but it turned out to be a Meckel’s diverticulum."
"It really is a coincidence. Seems like the incidence of Meckel’s diverticulum has been higher in recent years than before, hasn’t it?" Zhang Zhiyuan asked.
"I don’t have that data. But I think we’re going to keep seeing similar patients in the future, and there’s a good chance we’ll still diagnose them as appendicitis," Liu Banxia said.
"It’s just too hard to tell apart, and imaging can be very hard to distinguish as well. But overall we still have it easier than you guys. Every single patient who ends up in your unit needs extra caution."
"This time of year, it’s already much busier than before," Zhang Zhiyuan said with a wry smile.
This was just the two of them habitually complaining. In these two departments, there was really no such thing as an easy workload. The reason Liu Banxia looked relaxed was because that ease was built on the backs of the six juniors.
With them around, plenty of minor surgeries didn’t need doctors at Liu Banxia’s level to worry; the juniors could handle them entirely on their own.
Don’t be fooled by the label "minor surgery"; in day‑to‑day admissions, these kinds of patients still make up a large proportion.
"Teacher Liu, Teacher Liu, the result’s back, potassium is 1.9." After a few more lines of chatting, Liu Yiqing ran back.
Hearing that value shocked both Liu Banxia and Zhang Zhiyuan; it was really too low.
Basically a serum potassium of 2.5–3.0 is moderate hypokalemia; below 2.5 is severe. The patient’s current condition, including the ECG changes, was all being triggered by this.
"Use a central line and pump it in. That way the replacement can be faster. Otherwise, with a standard drip, the potassium might not be up by the time the patient crashes," Zhang Zhiyuan said.
Liu Banxia nodded. With the patient in this state, this was the only option. It also wasn’t appropriate to keep him here; he’d have to go to the ICU.
"Beep‑beep‑beep, beep‑beep‑beep..."
Just as Liu Banxia was about to make arrangements, the patient’s cardiac monitor suddenly started blaring alarms.
