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[Blocked from Release] 0901201701

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Topic updated on 09/01/17 9:51am

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


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