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She was unable to get out of bed and walk on the day of presentation. Past medical history was  significant for Gitelman's syndrome, with very labile, but generally very low, potassium levels being maintained on potassium sparing diuretics (eplerenone) and supplemental potassium 300 mEq/day. On presentation, she was afebrile with blood pressure, 106/51 mm of Hg; heart rate, 96 beats/min; respiratory rate, 16/min; and normal oxygen saturation on room air. Motor exam was significant for reduced power of 60 percent in both upper and lower extremities with flaccidity and diminished reflexes bilaterally. Sensation and cranial nerves were intact. Initial labs were as follows: sodium 131 mEq/L (range 135�C153 mEq/L), potassium 9.9 mEq/L (range 3.5�C5.3 mEq/L), blood urea nitrogen 41 mg/dL (range 5�C26 mg/dL), and creatinine 2.1 mg/dL with baseline of 1.0 mg/dL (range 0.50�C1.50 mg/dL). EKG showed dramatically widened QRS complex and tall broad T waves (Fig. 1). Emergent therapy for hyperkalemia was started with 1 g of intravenous calcium gluconate, 10 units of regular insulin with 50 g of dextrose, and 100 mEq of sodium bicarbonate. She also received albuterol nebulization and intravenous furosemide 120 mg. A dialysis line was placed and emergent dialysis was done with improvement of her potassium to 4.8 mEq/L post-dialysis. Neurological symptoms and EKG returned to baseline (Fig. 2). She subsequently  became hypokalemic requiring potassium repletion. Diuretics (torsemide, zaroxolyn, and eplerenone) were stopped and she was discharged on potassium chloride 60 mEq three times daily for maintenance. She shortly thereafter became profoundly hypokalemic and her maintenance dose of potassium was increased to 300 mEq/day. Fig. 1 Electrocardiogram (EKG) at presentation showing dramatically widened QRS complex and tall broad T waves. Fig. 2 EKG showing normalization of the rhythm to baseline after initial treatment of hyperkalemia. Discussion Potassium (K + ) is a very tightly regulated cation present ubiquitously inside  and outside all living cells. It is responsible for maintaining the cell membrane potential required for physiological functioning. As significant K+ gradient exists between inside and outside of cells, even a slight [http://www.selleckchem.com/products/byl719.html Alpelisib mouse] change in extracellular K+ level has a significant physiologic impact. Muscles, including the heart and nerves, are affected the most. The changes in K+ (hyper- or hypo-) have significant effect on heart muscle and its conduction system. Although absolute serum K+ level usually correlates with clinical symptoms, the rate of change is more important. EKG has an important role in detecting and delineating the effect of change. It is not very sensitive (0.34�C0.43) but the changes, if present, are specific (0.85�C0.86) (2, 3). The most widely used reference range for normal serum K+ level is 3.5�C5.5 mEq/L.