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Endocrine > Clinical Calcium > Flashcards

Clinical Calcium Flashcards

1
Q

What is normal calcium level and how do you work out correct calcium

A

2.2-2.6
Increased albumin will decrease free calcium as binds
Decreased albumin will increase free calcium

For every 10g decrease of albumin below 40 add 0.2 mol to measured calcium

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2
Q

What causes primary hyperparathyroid

A

Parathyroid adenoma = 80%
Parathyroid hyperplasia
Malignancy - MEN1/2A
Parathyroid cancer = rare

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3
Q

What does primary hyperparathyroid lead too

A 
PTH = high or normal (should be suppressed if Ca high) 
Calcium = high 
Phosphate = low as excreted or normal
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4
Q

What are the features of primary PTH / hypercalcaemia

A

Bone, stones, abdo groans, psychic moans

Dehydration - due to reduced sensitivity to ADH
Polyuria + polydipsia
Renal stones in chronic
AKI in acute

Bone pain 
Osteoporosis in chronic 
Weakness 
Fractures 
Lytic lesion if due to malignancy 
Abdo pain - renal stone / pancreatitis 
Constipation 
N+V 
Anorexia 
Weight loss
Peptic ulcer due to increased gastric secretion 
Fatigue / lethargy 
Depression - chronic
Psychosis 
Altered mental status / confusion
Cognitive impairment 
Seizure
Coma

In severe>3.5
HTN due to vasoconstriction - check Ca if HTN
Short QT
Cardiac arrhythmia

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5
Q

What causes secondary hyperparathyroid (decreased Ca but increased PTH)

A

Low calcium leading to increased PTH which eventually causes parathyroid hyperplasia
Often CKD
Decreased vit D
Leads to low absorption of Ca from intestines, kidney and bone

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6
Q

What does secondary hyperparathyroid lead too

A 
High PTH due to autonomous production after prolonged 
Doesn't sense calcium 
Ca low or normal 
Phosphate elevated or can be decreased
Low vit D as CKD
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7
Q

What are the symptoms

A

Begin to develop bone disease

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8
Q

What causes tertiary hyperparathyroid

A

On going parathyroid hyperplasia even after correction of renal disease so get high calcium
Will have abnormal U+E’s
High calcium ad high PTH

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9
Q

What does this lead too

A 
PTH high which is inappropriate 
Ca normal or high 
Phosphate low or normal
Vit D normal or decreased
ALP high
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10
Q

What are the symptoms

A 
Metastatic calcification
Bone pain
Fracture
Renal stone
Pancreatitis
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11
Q

How do you Rx primary hyperparathyroid and when

A

Surgical parathyroidectomy / remove tumour if
Raised serum calcium / life threatening
eGFR <60
Renal stone
<50
Neuromuscular Sx
Reduction in bone mineral density / osteoporosis on DEXA

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12
Q

How do you Rx secondary

A

Medical management of issue

Surgery if bone pain / pruritus / calcification

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13
Q

How do you Rx tertiary

A

Allow 12 months after transplant for symptoms to resolve

If not may need surgery to remove gland

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14
Q

What is hypercalcaemia requiring urgent correction due to risk of arrhythmia / coma

A

> 3.5

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15
Q

What are the most common reasons for hypercalcaemia

A

Primary hyperparathyroid
Malignancy
Do PTH to differentiate

Must rule out these first
Non-parathyroid mediated
- Malignancy = most common

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16
Q

What is also associated with primary hyperparathyroid

A

Neck radiation

Prolonged lithium

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17
Q

What are non-parathyroid causes of hypercalcaemia

A 
Hypercalcaemia of malignancy
Granulomatous - TB / sarcoid 
Iatrogenic
Activation of extra-renal 1 alpha hydroxyls (increases calcitriol) 
Vit D intoxiation
Familial hypocalciuric hypercalcaemia
Drugs 
Endocrine
Paget's
Parenteral nutrition
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18
Q

What causes hypercalcaemia of malignancy

A

Local osteolytic - breast / MM / lymphoma (20%)
Humoral - SCC / renal / ovarian (80%)
Lymphoma + ectopic = rare

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19
Q

What is familial hypocalciuric hypercalcaemia

A

AD of calcium sensing receptor
Less calcium excreted from body
No Rx needed

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20
Q

What drugs can cause hypercalcaemia with low PTH

A 
K sparing diuretic
Thiazide diuretic
ACEI
Lithium
Vit A
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21
Q

What are endocrine causes

A

Acromegaly
Thyrotoxicosis
Adrenal insufficiency - Addison’s
Phaeochromocytoma

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22
Q

What are symptoms of hypercalcaemia and what are common early and late Sx

A 
Renal
GI
MSK
Neuro
CVS

Early
- Polyuria / dispsia / dehydration / anorexia/. fatigue / weakness / hyporeflexia

Late

  • Irritable / low mood
  • N+V
  • Confusion
  • Profound weakness
  • N+V
  • Acute pancreatits
  • Pruritus
  • Visual
  • Sudden death
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23
Q

Renal Sx

A 
Dehydration 
Polyuria and dipsia due to imparied ADH 
Hypo of other electrolytes as lost in urine 
Nephrolithiasis (kidney stone) 
Nephrogenic DI
Renal tubular acidosis
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24
Q

GI Sx

A 
Anorexia / weight loss
N+V
Constipation
Pancreatitis
Peptic ulcer
Pruritus 
Ileus
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25
Q

What are MSK Sx

A

Muscle weakness / myopathy
Bone pain
Osteoporosis
Fractures

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26
Q

What are neuro Sx

A 
Decreased concentration
Fatigue
Low mood
Confusion = most common 
Coma
HYporeflexia
Seizures
27
Q

What are CVS Sx

A 
Short QT
Bradycardia
Various degree of heart block 
Hypertension
Fatal arrhythmia
28
Q

How do you investigate

A 
Hx - drugs + FH
Bloods
- Bone profile - Ca, phosphate, PTH
- U+E 
- Myeloma
- ALP 
- Amylase for pancreatitis
- Glucose for polyuria etc. 
ECG
X-ray / USS / CT head for confusion / MRI / isotope bone scan / CXR if suspect effusion
29
Q

If PTH normal or increases (inappropriate in hypercalcaemia)

A

Primary hyperparathyroid
Familial hypocalciuric hyperclacaemia
Tertiary

30
Q

If PTH low (appropriate for hypercalcaemia)

A

Malignancy

Drugs

31
Q

How do you Rx hypercalcaemia

A

Stop medication contributing - thiazide / vit D
Rehydration with normal saline = main stay
- 3L over 24 hours
Monitor U+E closely as can gt hypo K
IV biphosphonates if Ca >3 = main stay or not coming down with saline
Can use thiazide diuretic but only if overload as may cause other electrolyte
Monitor Ca and phosphates
Need to treat cause e.g. steroids If due to sarcoid

If >3.5 / coma/. arrhythmia
ICU for cardiac monitoring
Haemofiltration

32
Q

What should you monitor when dehydrated

A

Monitor for overload

Consider dialysis if severe renal failure so can’t use saline or biphhsophoantes

33
Q

What are 2nd line options

A

Glucocorticoid in lymphoma/. granulomatous
Calcitonin
Parathyroidectomy = 1st line primary
Calcimimetic - in primary

34
Q

What are causes of hypocalcaemia due to low PTH

A 
Destruction of parathyroid gland - surgery / thyroiditis 
Genetic
Autoimmune
Post surgery on thyroid
Hypomagnesium
Infiltration - mets / granulomatous
Radiation
Hungry bone
HIV
35
Q

Why hypoMg

A

Required for production of PTH

Drugs e.g. omeprazole can cause

36
Q

What is hungry bone syndrome

A

Low ca, phosphate and Mg after parathyroid surgery

37
Q

What causes hypocalcaemia due to high PTH (secondary hyperparathyroid)

A 
Chronic renal disease
Vit D deficiency (osteomalacia) 
Pseudohypoparathyroid
Rhabdomylosis
Tumour lysis 
Acute pancreatitis
Blood transfusion - cause metabolic alkalosis
Acute respiratory alkalosis
38
Q

How does tumour lysis cause

A

High phosphate and K as releases

Promotes reabsorption in bone

39
Q

What is pseudohypoparathyroid

A

Target organ unresponsive to PTH
Leads to hypocalcaemia but hyperphosphataemia
PTH rises due to low Ca but organ doesn’t respond to increase
Rx as per primary hypoparathyroid

40
Q

What is Albright’s Hereditary Osteodystrophy

A 
Pseudohypoparathyroid + 
Obesity
Short stature
Low IQ
Shortening of metacarpals - 4th and 5th
41
Q

What is pseudo-pseudo hypoparathyroid

A

AHO but normal biochemistry

42
Q

What drugs cause hypocalcaemia

A 
Biphosphonates 
Loop diuretic 
Phenytoin
Fluoride
Calcium chelator
43
Q

What are acute signs of hypocalcaemia

A 
Tetany
Paraesthesia
Muscle twitching / spasms
Trousseau's
Chovstek's
Seizure
Bronchospams 
Cardiac
Papilloedema
44
Q

What are cardiac signs

A

Prolonged QT
Hypotension
HF
Arrhythmia

45
Q

What is Trousseau’s and Chovstek’s

A

Trousseau - tight cuff applied to occlude brachial = wrist flexion, fingers cuff, paraesthesia + bronchospasm
Chovstek - touch facial nerve = spasm of muscles

46
Q

What are chronic signs of hypocalcaemia

A 
Extra-pyramidal
Parkinsonism
Dementia
Depression
Cataract
Abnormal dentition
Dry skin
47
Q

How do you investigate

A

Hx
Bloods
ECG

48
Q

What is important in Hx

A 
Ca + vit D intake
Autoimmune disease
Surgery to neck
Drug Hx
FH
49
Q

What bloods

A

Calcium, albumin, phosphate, vit D, phosphate, Mg, U+E

50
Q

If calcium low what do you check next

A

PTH

51
Q

If PTH = low or normal (should be high)

A

Check Mg
If Mg low = deficiency
If normal = hypoparathyroid

52
Q

If PTH high

A

Check U+E

If high = renal failure

53
Q

What do you do if U+E normal

A

Check Via D
If low = vit D deficiency
If normal = pseudo

54
Q

How do you treat mild hypocalcaemia

A 
Oral calcium
Vit D if defiicent
Replace Mg
Stop precipitating drugs
Advise diet
55
Q

What do you do in severe hypocalcaemia

A

IV calcium gluconate bolus 10-20ml 10% in 50-100ml of 50% dextrose over 10 minutes
Continuous ECG
Rx cause

56
Q

What is MEN Type 1

A 
MENIN Mutation 
3P's
Primary hyperparathyroid - most common presentation
Pancreatic and duodenal insulinoma
Pituitary adenoma

Other
- Adrenal / thyroid

57
Q

What is MEN 2A

A 
RET mutation 
2P's
Primary hyperparathyroid
Phaeochromocytoma
Medullary thyroid cancer
58
Q

What is MEN 2B

A 
RET mutation
1P
Phaeochromocytoma
Medullary thyroid
Neuroma of skin
59
Q

When do you screen for MEN1

A

Symptoms suggestive. +
Male and hyperparathyroid <50
2 MEN-1 tumours
1st degree with EMN1

60
Q

What are suggestive symptoms

A 
Hypercalcaemia and renal calculi
Peptic ulcer
Unexplained hypoglycaemia
Hyperprolactin
Acromegaly
Hypopituitary
61
Q

How do you Rx

A

Surgical excision

Medical / RT depending on tumour type

62
Q

When do you screen for MEN2

A

Any patient with medullary cancer as usual presentation
MEN2 tumour <30 or 2 >30
Neurofibromatosis
1st degree relative with MEN2

63
Q

What causes primary hypoparathyroid

A 
Gland failure 
- RT
- Surgery 
Autoimmune
Congenital
Hypo-Mg
64
Q

How do you Rx

A

Ca supplements + calcitriol

Endocrine (17 decks)

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