questions 8

Hypocalcemia vs. Hypercalcemia

Topic updated on 06/27/17 2:04pm

Hypocalcemia Hypercalcemia
 hypocalcemia   hypercalcemia 
  • A 45-year-old male with a history of medullary thyroid cancer presents with abdominal pain, muscle cramps, and tetany. On PE he has facial nerve twitching after tapping. EKG shows a prolonged QT interval. 
  • A 65-year-old with multiple myeloma presents with confusion, severe depression, vomiting, constipation, and polyuria. EKG shows shortened QT interval. 
Introduction Introduction
  • Causes include
    • hypoparathyroidism
    • acute pancreatitis
    • medullary thyroid cancer
    • hypomagnesium
    • lack of vitamin D 
    • blood transfusion
  • Serum pH affects the homeostasis of the 3 forms of plasma calcium (ionized calcium, albumin-bound calcium, and calcium bound to inorganice and organic anions). 
    • increase in pH can result in reversible symptoms of hypocalcemia  
  • Causes include
    • malignancy (most common symptomatic cause)
    • hyperparathyroid disorders (most common asymptomatic cause)
    • bone disorders
    • kidney disorders
    • immobilization
Presentation Presentation
  • Symptoms
    • abdominal pain
    • tetany
    • muscle cramps
    • dyspnea
    • perioral tingling
    • convulsions
    • mental status changes
  • Physical exam
    • hyperactive reflexes 
    • carpal tunnel spasm after blood pressure readings (Trousseau's Sign)
    • facial muscle contractions after tapping on the facial nerve (Chvostek's Sign)
  • Symptoms
    • bones
      • fractures
    • stones
      • nephrolithiasis
    • groans
      • anorexia
      • vomiting
      • constipation  
    • psychic overtones
      • weakness
      • fatigue
      • altered mental status
Evaluation Evaluation
  • EKG may show
    • prolonged QT interval 
  • Lab differential workup should include
    • calcium
    • phosphate
    • PTH
    • TSH
    • vitamin D
  • Of note, individuals with low albumin can have low total plasma calcium
    • since their levels of ionized calcium are relatively normal, they may be asymptomatic 
  • EKG may show
    • QT interval shortening 
  • Lab differential workup should include
    • calcium
    • phosphate
    • PTH
    • TSH
    • vitamin D
    • albumin
Treatment Treatment
  • Treat underlying cause
  • Give calcium gluconate
  • Vitamin D supplement
  • Calcium restriction
  • IV hydration (watch for CHF)   
    • followed by furosemide diuresis ("loops lose calcium")
  • In severe cases:
    • calcitonin
    • pamidronate (and bisphosphonates especially for hypercalcemia of malignancy) 
    • corticosteroids
  • Avoid thiazide diuretic


Qbank (6 Questions)

(M2.RL.3) A 64-year-old man presents for a routine physical. He states that he is not doing very well and, in fact, has not had a bowel movement in over a week. Upon further questioning, the patient notes that for about 4 months he has experienced significant back pain and finds that he is easily fatigued. His wife has remarked that he is unusually "pale." In addition to his lack of a bowel movement for the past week, the patient has also had a loss of appetite, has been urinating more than usual, and has had a depressed mood. Which of the following is the most likely cause of this patient's constipation? Topic Review Topic

1. Hyperkalemia
2. Hypermagnesemia
3. Hypophosphatemia
4. Hypercalcemia
5. Hypocalcemia

(M2.RL.24) A 27-year-old female suffers from a panic disorder. She describes her typical panic attack with the symptoms of sweating, palpitations, chest pain, and hyperventilation. She also reports feeling perioral numbness. Which of the following is the most likely physiological cause of this localized numbness? Topic Review Topic

1. Increased blood pH
2. Decreased blood pH
3. Decreased albumin-bound calcium
4. Decreased total blood calcium concentration
5. Decreased blood oxygen concentration

(M2.RL.25) A 18-year-old female presents to her primary care physician for a pre-sports physical. She has no prior medical history except that her mother states she has recently lost weight and that she has become concerned about her weight. On physical exam she is 5’6” and weighs 102 lbs. A serum electrolyte panel is drawn, which reveals a calcium level of 8.5 mg/dL. Serum albumin is 3.0 g/dL. What is this patient’s corrected serum calcium level? Topic Review Topic

1. 8.4 mg/dL
2. 8.7 mg/dL
3. 9.0 mg/dL
4. 9.3 mg/dL
5. 9.5 mg/dL

(M2.RL.31) A 30-year-old woman is brought to the emergency department following a major automobile accident in which she was an unrestrained passenger. She has no significant past medical history and takes no medications. Her temperature is 37.5 C (99.5 F), blood pressure is 70/40 mm Hg, heart rate is 120/min, and respiratory rate is 22/min. On physical exam, she is in acute distress due to pain. She is alert and oriented to person, place, and time, with no signs of head trauma. She has chest wall bruising bilaterally with tenderness to palpation. Cardiac and pulmonary auscultation are within normal limits. Her abdominal exam reveals tenderness to palpation with rebound. There is also severe pain with palpation and passive movement of the right hip. Given this patient's hemodynamic instability, she is taken to the operating room, where exploratory laparotomy reveals a splenic laceration and significant hemoperitoneum. She receives twelve units of packed red blood cells during the procedure. On the first post-operative day, her physical exam reveals hyperactive deep tendon reflexes. Which of the following electrolyte abnormalities is most likely present? Topic Review Topic

1. Hypercalcemia
2. Hypocalcemia
3. Hyperkalemia
4. Hypokalemia
5. Hypermagnesemia

(M2.RL.42) A 40-year-old woman with a history of triple negative metastatic breast cancer presents with colicky groin pain and hematuria. CT of the abdomen and pelvis reveals the following (shown in Figure A). She also reports several days of constipation, weakness, and confusion. Vital signs are as follows: Temp 37 C, HR 90, BP 110/70, RR 12, and O2 99% on room air. Physical examination is within normal limits. Serum calcium is 14 mg/dL (normal range 8.5-10.3). PTH is 5 pg/mL (normal range 11-54). A PTHrP is pending. Besides starting IV normal saline, long-term therapy with which of the following should be started: Topic Review Topic
FIGURES: A          

1. A medication that may cause gray baby syndrome
2. A medication that may cause osteonecrosis of the jaw
3. A medication that may cause coronary vasospasm
4. A medication that may cause pulmonary fibrosis
5. A medication that may cause hot flashes

(M2.RL.143) A 70-year-old male is diagnosed with multiple myeloma after several months of persistent back pain. One week after his diagnosis he presents to the ED with acute onset confusion, vomiting, and constipation. He produces 750ml of urine in one hour. His vitals are BP 150/90, HR 55, T 98.3, SpO2 98%. His EKG is shown in Figure A. What is the next best step in his management? Topic Review Topic
FIGURES: A          

1. Hydrochlorothiazide
2. IV sodium bicarbonate
3. IV normal saline and calcium carbonate
4. Naloxone
5. IV normal saline

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