CBL - 13 Flashcards
A 69-year-old man attends his GP with his wife complaining of a three month history of abdominal pain, constipation and feeling generally very low in mood.
Q1. What areas of the history would you ask about? [+]
History; ask about:
- Skeletal symptoms: bone pain; osteoporosis; skeletal
- Neuropsychiatric symptoms drowsiness; impaired concentration ability; confusion; depression; irritability; psychosis; ataxia; hypotonia; insomnia
- Neuromuscular symptoms: fatigue, muscle weakness;
- GI symptoms: N & V; anorexia; WL; consipation; abdominal pain
- Renal symptoms: renal colic; thirst (polyuria, polydipsia, nocturia, and dehydration)
- CV symptoms: hypertension; shortened QT interval;
Medications that can cause hypercalcemia include:
- Thiazide like diuretics
- Too much vit. D supplement
- Lithium
What questions should you ask regarding constipation? [+]
Establish timeline about constipation:
- Timeline
- Fibre intake?
- When did you last open your bowels?
- How often do you move your bowels?
- Have you noticed any change in the bulk of your stools?
- Do you feel that you have emptied your bowels entirely after you go to the toilet?
- What medication might take?
- Weight loss?
- Associated fever, nausea, vomiting, loss of appetite and/or weight?
What are red flag questions for stool questions? [+]
A 69-year-old man attends his GP with his wife complaining of a three month history of abdominal pain, constipation and feeling generally very low in mood.
Q1. What areas of the clinical examination would you ask about [+]
- Hydration status
- LNs and breast mass (if suspect someone with hypercalcemia secondary to malignany)
- High BP (hypercalcemia and renal failure)
- Assess for cognitive impairment
What investigations would you consider? [+]
FBC:
- diagnose or exclude anaemia of chronic disease or haematologic malignancy
HbA1C
- DMT2 gastroparesis
U&Es
ESR or CRP:
- may be increased in malignancy or other inflammatory or granulomatous conditions.
eGFR:
- assess hydration status
- AKI ?
- CKD?
Serum and urine protein electrophoresis:
- urine Bence-Jones protein — to exclude myeloma
LFTs:
- liver metastases or chronic liver failure
- alkaline phosphatase may be increased in primary hyperparathyroidism
- myeloma
Thyroid function tests
- to exclude thyrotoxicosis
Vitamin D & Ca2+ levels
PTH:
- raised in primary (and tertiary) hyperparathyroidism
- suppressed or undetectable in malignancy-related hypercalcaemia or other non PTH-dependent causes.
Serum cortisol
- if Addisons disease suspected
His GP organises some routine blood tests, prescribes him some medication for his constipation, and decides to refer him for a two week wait cancer investigation for possible bowel cancer.
A few days later, however, the patient starts developing severe right loin pain, radiating to the groin. The pain is so bad that his wife calls an ambulance who take him to the Emergency Department.
In the Emergency Department he is noted to have severe pain and tenderness in the right loin. He is unable to stay still on the examination couch.
Urinalysis shows blood ++, but nil else.
Q2. What is the likely cause of his acute pain? [2] What treatment should be given and what investigation should be done?
AKI picture:
* Kidney stone
* Pyelonephritis
Q2. What is the likely cause of his acute pain?
What investigation should be done?
Kidney stone:
- For most adults, offer low-dose non-contrast CT KUB
- If pregnant offer US
What treatments should be given? [4]
IV fluids
Pain relief:
- IM diclofenac
- Paracetamol IV
- (opoids)
If less than < 5mm:
- Watchful waiting
If more than > 5mm
- shockwave lithotripsy
- ureteroscopy
- percutaneous nephrolithotomy
How do CT-KUBs get reported from radiologists? [3]
Bowels and other organs
Bones
Calcification and artefact
State the different therapeutic selections for kidney stones that are:
Stone burden of less than 2cm in aggregate [1]
Stone burden of less than 2cm in pregnant females [1]
Complex renal calculi and staghorn calculi [1]
Ureteric calculi less than 5mm [1]
Stone burden of less than 2cm in aggregate
- Lithotripsy
Stone burden of less than 2cm in pregnant females:
- Ureteroscopy
Complex renal calculi and staghorn calculi:
- Percutaneous nephrolithotomy
Ureteric calculi less than 5mm:
- Manage expectantly
Q3. What abnormalities are seen? What further investigations should be undertaken? [2]
- Renal stone in right ureter
- Constipation - bowel looks enlarged and full on R
Q3. What abnormalities are seen? What further investigations should be undertaken? [6]
Bone profile & Urate levels - ID cause of stones
FBC & CRP
- UTI?
Daily U&Es
- Check AKIs (and see if changes)
Urine MC&S
Urine pH
24hr urine collection for calcium, oxalate, urate citrate, sodium, creatinine
How do you acutely manage hypercalcemia in this patient [3]
0.9% saline
Bisphosphinates: zoledronic acid (dose depends on the eGFR of the patient)
Calcitonin - inhibits (blocks) the activity of osteoclasts, which are cells that break down bone
What are the reasons for hypercalcaemia? [+]
Primary hyperparathyroidism:
- Parathyroid adenomas
Tertiary hyperparathyroidism:
- autonomous PTH excess due to parathyroid hyperplasia in response to longstanding secondary hyperparathyroidism: CKD
Thyrotoxicosis:
- Elevated thyroid hormones can lead to thyroid hormone-mediated bone resorption. Mild hypercalcaemia can be seen in up to 20%.
FHH
- FHH is an autosomal dominant condition caused by a mutation to calcium-sensing receptors (CaSR). CaSRs play an important role in calcium regulation.
Sarcoidosis
Hypervitaminosis D
Iatrogenic:
- Chronic lithium use: enhances PTH release
- Thiazide diuretics: lowers urinary calcium excretion
Malignant hypercalcaemia:
- due to release of parathyroid related peptide (PTHrP)