In the latest in our monthly series, Dr James Chambers asks readers to suggest what’s causing ongoing nausea and tingling fingers in this older woman. Put your answers in the comments.
You see a 64-year-old woman in your afternoon clinic. She tells you that she is sorry to bother you, but this awful nausea just isn’t going away. On probing deeper, you find she has been feeling nauseous daily for around 3 months now. It began as an occasional feeling when cooking or smelling food but quickly became more constant, although it has never made her vomit.
While her weight has remained stable up to now, the patient has noticed the nausea is affecting her appetite, and she is worried she will soon start to lose weight if nothing is done. She reports no problems swallowing and no pain in her stomach or changes in bowel habits. She has already tried altering her diet to include more plain foods and apart from complaints from her husband, it has made little difference.
The only other change the patient has noticed is some tingling in her fingers, which is often worse at night when she tries to sleep. Her neighbour told her it was probably just carpal tunnel syndrome, although the wrist splint she bought online doesn’t seem to be helping.
Looking at her notes, you notice she has a history of hypertension, diabetes and GORD. Her medications include amlodipine, metformin and omeprazole. You can see she very rarely comes to see you and is recorded as a non-smoker.
On examination, you record the following observations: heart rate 74; respiratory rate 16; BP 135/90; O2 Sats 99%; temperature 36.7 degrees.
You find that her chest sounds clear with normal heart sounds. Her abdomen feels soft and non-tender with normal bowel sounds. On neurological assessment her tone, power and reflexes are all normal. She has normal visual acuity and perception. You can’t find any objective sensory loss on examination either.
Unsure of the cause of her symptoms, you arrange for some routine blood tests which reveal the following: FBC normal; U&E normal; LFT normal; serum CRP normal; serum calcium 2.0 mmol/L ( reference 2.20-2.60); serum albumin 35 g/dl ( reference 35-50); serum ALP 120 U/L ( reference 30-130); serum PTH 8.07 pmol/L (reference 1.95-8.49); serum total 25-OH vitamin D 75 nmol/L (reference 50-150).
What blood test would you now consider? Put your suggestions in the comments below! Answer to be revealed soon…
Dr James Chambers is a GP Registrar in Staffordshire
Well, seeing as we are not allowed to do a vitamin D test in GP; I would certainly have done first a Thyroid function test (TSH and T4), and also B12 and folate from her symptoms despite normal FBC; and given that she is on metformin, an HbA1C (although in theory we should have TFT and HbA1C in her notes already from a recent test, given the Diabetes.)
Now that we know about the hypocalcaemia, can we also get an eGFR, serum Magnesium level, and morning cortisol?
PPI related
Next you’d want to check her magnesium level.
Low magnesium, probably caused by a combination of the PPI, amlodipine and diet, impairs PTH production and action leading to secondary hypocalcaemia. PTH level is normal which rules out primary hypoparathyroidism.
Interesting case, thanks James!
Agreed probs meds related.
Vit D already normal. Magnesium, PO4, and TSH might help.
Also her PTH should be higher for this Calcium. Albumin lower end of normal is interesting too. Good case to chew over in a tutorial.