To which hospital floor should a 54-year-old man with chronic alcohol use, prior Roux‑en‑Y gastric bypass, hypokalemia, hypocalcemia, and anemia presenting with symptomatic finger cramping be admitted?

Hospital Floor Admission Decision

This patient requires admission to a telemetry or intermediate care unit (step-down unit) with continuous cardiac monitoring, not a general medical floor or ICU. 1

Rationale for Telemetry/Intermediate Care Unit

The combination of severe electrolyte abnormalities (hypokalemia and hypocalcemia) with symptomatic manifestations (finger cramping/tetany) mandates continuous cardiac monitoring due to high risk of life-threatening arrhythmias, particularly torsades de pointes. 1

Key Clinical Factors Supporting This Decision:

• Severe hypokalemia with chronic alcohol use creates substantial risk for cardiac arrhythmias and requires cardiac monitoring until electrolyte disorders are corrected 1, 2

• Symptomatic hypocalcemia (manifesting as tetany/cramping) indicates severe depletion requiring frequent monitoring and therapeutic intervention 1

• Post-RNY gastric bypass status (10 years out) predisposes to multiple nutritional deficiencies including iron-deficiency anemia (explaining low H/H), hypocalcemia, and hypomagnesemia 3, 4

• Daily alcohol consumption compounds electrolyte abnormalities through inappropriate kaliuresis (often due to coexistent hypomagnesemia) and increases risk of withdrawal complications 2

Specific Monitoring Requirements on Telemetry Unit:

The pediatric intermediate care guidelines provide the clearest framework applicable to adults with severe electrolyte disorders 1:

• Continuous cardiac rhythm monitoring for detection of QT prolongation, ventricular arrhythmias, and bradyarrhythmias 1

• Frequent vital sign assessment (every 2-4 hours initially) 1

• Serial electrolyte monitoring every 4-6 hours during active repletion of potassium, calcium, and magnesium 1

• ECG monitoring for QT interval changes during electrolyte correction, as severe hypokalemia and hypomagnesemia prolong QT and predispose to torsades de pointes 1

Why NOT ICU:

This patient does not meet criteria for ICU admission because he lacks 1:

• Hemodynamic instability (no hypotension or shock)
• Respiratory compromise requiring mechanical ventilation
• Ongoing cardiac ischemia or acute coronary syndrome
• Altered mental status requiring intensive neurological monitoring
• Active life-threatening arrhythmias at presentation

Why NOT General Medical Floor:

A general medical floor is inadequate because 1:

• Severe hypokalemia (K+ <2.5 mEq/L based on symptomatic presentation) requires cardiac monitoring during correction 1

• Symptomatic hypocalcemia with tetany indicates severe depletion requiring more intensive monitoring than available on general floors 1

• Risk of cardiac arrhythmias during electrolyte repletion necessitates continuous telemetry 1

• Alcohol withdrawal risk in daily drinkers requires closer observation than general floor nursing ratios allow 2

Critical Management Priorities on Telemetry:

• Verify potassium level immediately with repeat sample to rule out pseudohyperkalemia from hemolysis, and obtain ECG to assess for QRS widening or peaked T-waves 1

• Check magnesium level urgently as hypomagnesemia is the predominant cause of inappropriate kaliuresis and refractory hypokalemia in alcoholic patients 2

• Assess for alcohol withdrawal using CIWA-Ar protocol, as withdrawal can cause respiratory alkalosis that further exacerbates hypokalemia 2

• Evaluate anemia severity (likely iron-deficiency from RNY malabsorption) and consider transfusion if hemoglobin <7-8 g/dL or if symptomatic 1, 4

• Screen for vitamin D deficiency and renal function as both significantly increase risk of hypocalcemia post-RNY 3

Common Pitfalls to Avoid:

• Do not correct potassium without simultaneously correcting magnesium – hypomagnesemia causes refractory hypokalemia through inappropriate renal potassium wasting 2

• Avoid rapid calcium correction if phosphate is elevated – increases risk of calcium-phosphate precipitation and obstructive uropathy 1

• Monitor for calcium-induced bradycardia during IV calcium gluconate administration for symptomatic hypocalcemia 1

• Do not discharge until electrolytes normalized and patient observed stable for 24 hours – delayed complications are common 1