Lessons of the month 2: A forgotten cause of transient T-wave inversion.

A 19-year-old patient presented with severe chest pain, which is not typical for cardiac angina. However, his smoking history and the strong family history of ischaemic heart disease coupled with evidence of progressive T-wave changes on his electrocardiogram (ECG) caused dilemma in deciding further management. His blood tests were normal apart from hypophosphataemia, and he had two negative troponin results. His arterial blood gases showed respiratory alkalosis. He was given analgesia for a diagnosis of musculoskeletal chest pain and the next morning his ECG, arterial blood gases and phosphate levels all normalised. He had a normal echocardiogram and was reviewed by the cardiologist who diagnosed musculoskeletal chest pain which led to distress and hyperventilation causing hypophosphataemia and transient T-wave inversion. This case is a reminder of an under-recognised physiological phenomenon involving the cardiac conduction during hyperventilation.

Diabetes care during Hajj.

Keeping well during Hajj is a challenge for people with diabetes. However, with proactive planning and education, it may prove to be an excellent opportunity for reviewing management and enhancing diabetes education to reduce diabetes-related short- and long-term problems. People with diabetes should have enough time to consider a management plan. It is important that healthcare professionals are well informed regarding the effects of Hajj on diabetes and are able to offer advice, guidance and change of medications as required during pre-Hajj counselling to enable patients to stay healthy.