A 53 year old female presents unwell with blood tests suggesting the following:

Normal anion gap (hyperchloraemic) metabolic acidosis without compensation

Severe hypokalaemia

Low Hb

These are suggestive of NSAID (Nurofen) toxicity, often seen in patients using over the counter preparations of codeine which often have nurofen as part of the combination analgesic. Causes a typr II (Must look for GI bleed in this patient.

A rectal exam is mandatory and a urea level ay be helpful to suggest upper GI bleeding

ECG changes of hyperkalaemia (usually when K <2.7 mmol/l)

• Increased amplitude and width of the P wave
• Prolongation of the PR interval
• T wave flattening and inversion
• ST depression
• Prominent U waves (best seen in the precordial leads)
• Apparent long QT interval due to fusion of the T and U waves (= long QU interval)

As the hyperkalaemia worsens:

• Frequent supraventricular and ventricular ectopics
• Supraventricular tachyarrhythmias: AF, atrial flutter, atrial tachycardia
• Potential to develop life-threatening ventricular arrhythmias, e.g. VT, VF and Torsades de Pointes