Endocrine Flashcards
What are the symptoms of hypothyroidism?
- Constipation
- Menorrhagia
- Weight gain + loss of appetite
- Lethargy + weakness
- Cold intolerance
- Infertility
- Loss of libido
- Poor memory/ cognition
- Low mood
What are the signs of hypothyroidism?
- Bradycardia
- Delayed tendon reflex relaxation
- Jaundice
- Pitting oedema + ascites
- Cold hands
- Peripheral neuropathy
- Myxoedema- puffy hands/ feet/ face
- Pleural effusion
- Overweight
- Carpal tunnel
- Goitre
- Cerebellar ataxia
Causes of hypothyroidism
- Primary (Low T3/4, High TSH)
- Primary atrophic hypothyroidism (no goitre)
- Hashimoto’s (goitre)
- Iodine deficiency
- Post-thyroidectomy/ radioactive iodine
- Drug induced- antithyroid, amiodarone, lithium, iodine
- Secondary (Low T3/4 and TSH) = hypothalamus/ pituitary dysfunction.
Ix and Tx of hypothyroidism
- Ix- TFTs, autoantibodies, cholesterol/ triglycerides
- Tx= levothyroxine. Start low (50 micrograms OD) and titrate up monthly. Once stable –> yearly bloods.
- Elderly/ cardiac disease start 25 micrograms.
Presentation of myxoedema coma
- Usually >65y
- Hypothermia
- Cyanosis
- Hyporeflexia
- Hypoglycaemia
- Bradycardia
- Coma/ seizures
- Preceding psychosis (myxoedema madness)
- Signs/ Sx of hypothyroid eg goitre. Prev radiodine/ thyroidectomy
Ix and Tx of myxoedema coma
- Ix- ECG, TFTs, FBC, U+Es, cultures, cortisol, glucose, ABG. ??Cause
- Tx: In ITU
- ABCDE +/- O2 + cautious IVT
- Warming blanket
- Correct hypoglycaemia
- T3 (liothyronine) IV 2-3d –> Levothyroxine PO
- Hydrocortisone if ?pituitary
- ABx if ?infection
Symptoms of hyperthyroid
- Weight loss + increased appetite
- Diarrhoea/ fatty stools
- Sweats
- Heat intolerance
- Loss of libido
- Oligomenorrhoea
- Irritability
- Tremor
- Palpitations
Signs of hyperthyroid
- Proximal myopathy
- Osteoporosis
- Fine tremor
- Palmar erythema
- Goitre
- Thin
- Exophthalmos/ ophthalmoplegia/ lid lag / lid retraction
- Moist skin
- Tachycardia
Causes of hyperthyroidism
- Graves’ disease= AI. Thyroid enlargement and increased thyroid hormone production
- Toxic multinodular goitre- Nodules secreting more thyroid hormone
- Toxic adenoma- Solitary nodule secreting T3/T4. Hot on isotope uptake
- Ectopic thyroid tissue eg metastatic thyroid cancer
- Exogenous- iodine excess, levothyroxine, amiodarone, lithium
- Thyroiditis- Destruction –> release hormones
- de Quervain’s- self-limiting post-viral goitre. High temp/ESR. Decreased isotope uptake.
- Post-partum
- TB
- Secondary- pituitary/ hypothalamus. RARE.
Hyperthyroid investigations
- Bedside- ECG
- Bloods- TFTs, FBC, ESR, calcium, LFTs, thyroid autoantibodies
- Imaging- USS, isotope uptake scan
- ? Eye testing
Treatment of hyperthyroid
- Medical:
- Beta blockers (rapid)
- Titration- carbimazole titrated to TFTs
- Block and replace- carbimazole + thyroxine
- Graves’ Tx for 12-18 months –> stop. 1/2 relapse.
- Radioiodine
- Thyroidectomy (risk: recurrent laryngeal n.)
Presentation of thyroid storm
- Signs/ Sx of hyperthyroid
- Hyperthermia
- Agitation
- Confusion
- Coma
- Tachycardia
- AF
- D+V
- Goitre
- Thyroid bruit
- HF
- Acute abdo
Ix and Tx of thyroid storm
- Ix- TFTs, culture, isotope uptake. Don’t delay Tx
- Tx:
- ABCDE + IVT
- ?Sedate- chlorpromazine
- Propranolol (diltiazem if asthma/HF)
- ?Digoxin to slow heart
- Antithyroid drugs- carbimazole (reduce after 5d) –> Lugol’s solution (iodine) for 7-10d.
- Hydrocotisone/ dexamethaone
- ?ABx
- Cool fluid, paracetamol
Features and treatment of mild/ subclinical hypothyroid
- Raised TSH, normal T3/T4, no obvious Sx
- Recheck TFTs 2-4 months later to check persistence.
- Tx if TSH >10/ autoantibodies/ past Tx Graves’/ other AI
- TSH 4-10 –> trial Tx 6 months and stop if Sx don’t improve
- No Tx –> monitor yearly TFTs
Features and Tx of mild/ subclinical hyperthyroid
- Low TSH, normal T3/T4
- Recheck TFTs 2-4months. Check for non-thyroid cause eg pregnancy, illness
- TSH <0.1 Tx if Sx of hyperthyroid/ AF/ unexplained weight loss/ osteoporosis/ goitre
- Tx- carbimazole, propylthiouracil
- No Sx –> recheck 6 monthly
Signs of Graves’ Disease
- Eyes- ophthalmoplegia, exophthalmos
- Pre-tibial myxoedema
- Thyroid acropachy (clubbing)
Goitre differentials
- Diffuse
- Iodine deficiency
- Physiological- puberty, pregnancy
- Congenital
- AI- Graves’, Hashimoto’s
- Nodular
- Multinodular goitre
- Cyst
- Adenoma (hot)
- Malignancy (cold)
Types of thyroid cancer + Tx
- Papillary (60%). Younger. Tx- total thyroidectomy+ node excision + radioactive iodine + thyroxine
- Follicular (25%). Older. Tx as above.
- Medullary- MEN. Calcitonin. Thyroidectomy
- Lymphoma- stridor/ dysphagia. chemo/ radio
- Anaplastic- elderly. Poor response to Tx.
Hyperglycaemic symptoms
- Polydipsia
- Polyuria
- Ketotic breath (pear drops)
- Sweet smelling urine
- Fatigue
- Weight loss
- Susceptible to infection eg thrush
What makes the Dx more likely to be T1DM and not T2DM?
- T1DM= absolute insulin deficiency –> insulin
- Young
- Thin
- Usually no FHx
- Complications not usually present at Dx
What makes the Dx more likely to be T2DM and not T1DM?
- Relative insulin deficiency
- Gradual onset. Usually adults.
- Obese.
- Usually 1st degree relative.
- Complications often present at Dx
Features of MODY
- Genetic –> strong FHx
- Present young but don’t always need insulin
Features of LADA
- T1DM in adulthood.
- Slower onset.
- Rapid progression to insulin
- May present with DKA
Secondary causes of DM
- Pregnancy (GDM)
- Cushing’s
- Acromegaly
- Pancreatitis
- Hyperthyroid
- Haemachromatosis
- Steroids
What is metabolic syndrome?
- Cluster of conditions:
- Central obesity
- BP >130/85
- Fasting BM >5.6 mmol/L
- High triglycerides and HDL
- Increased risk of: DM, heart diease, stroke, gallstones, cancer.
- Tx= usually diet and exercise.
WHO diagnostic criteria for DM
- Sx of hyperglycaemia and 1x elevated venous blood glucose:
- Fasting >7mmol/L
- Random >11.1mmol/L
- 2x elevated venous blood glucose (or OGTT 2h >11.1 mmol/L)
- HbA1c >48 mmol/L (only T2DM)
Complications of DM
- Macrovascular:
- Heart- MI, angina, CHF, HTN
- Brain- CVA, TIA, cognitive impairment
- PDV- Ulcers, gangrene, claudication, amputation
- Microvascular:
- Kidney- nephropathy (frothy urine)
- Eye- retinopathy, maculopathy, cataracts, glaucoma
- Neuropathy
- Erectile dysfunction
- Ischaemic foot
- Emergencies- Hypo, DKA, HHS
Causes of hypoglycaemia
EXPLAIN
- EXogenous- insulin, gliclazide, alcohol, aspirin, ACEi, beta blockers
- Pituitary insuffiency
- Liver failure
- AKI/ Addison’s
- Islet cell tumours (insulinoma) + Immune Hypo
- Neoplasm (non-pancreatic)
Presentation of hypoglycaemia
- ‘Drunk’
- ANS- sweating, palpitations, hunger, dizziness
- Neuroglycopoenic- Coma, confusion, drowsiness, difficulty speaking, seizure, incoordination, visual disturbance
Emergency treatment of hypoglycaemia
- ABCDE
- Correct glucose
- Can swallow- 10-20g glucose PO eg juice, biscuits, glucogel
- Cannot swallow- 1mg glucagon IM/SC OR 100ml 10% glucose/ 50ml 20% glucose over 20mins
- Repeat until glucose over 4mmol/L
- Long acting carbs eg toast
Presentation of DKA
- Drowsy/coma
- Dehydration/ shock
- Kussamul breathing (deep and laboured)
- Ketotic breath
- Abdo pain
- Vomiting
- Weakness
- Hyperglycaemic Sx
Diagnosis of DKA
- BM, urine, ABG
- Glucose >15mmol/L
- Raised urine/ blood ketones
- pH <7.3
Management of DKA
- ABCDE
- IVT- 6L in 1st 24h. IL stat –> 1hour –> 2h –> 4h –> 8h
- Sliding scale insulin actrapid- 0.1 units/kg/hour. Stop reg. short acting.
- Hunt for trigger
- K+ replacement after 1st bag (40mmol/L)
- Monitor: BM, K+, VBG (pH, bicarb, glucose, K+)
- BM <14 –> Add 10% glucose 125ml/h
- Stop insulin when ketones <0.3, pH >7.3, bicarb >18mmol/L. Rapid acting –> stop 30mins later
- LMWH
Presentation of HHS
- Subacute- around 1w
- Nausea
- Dry skin
- Profound dehydration
- Reduced consciousness + confusion
- Polyuria
- Polydipsia
- Lethargy
HHS Dx
- Glucose >35mmol/L
- Osmolality >340mosmol/kg
- No acidosis
HHS management
- Slow IVT over 28h
- Replace K+ when passed urine
- Aim glucose to fall 5mmol/L/h –> if not, add 0.05units/kg/h insulin
- LMWH
Key features of diabetic retinopathy
- Background- Microaneurysms, hard exudates, blot haemorrhages
- Pre-proliferative- Blot haemorrhages, venous bleeding, cotton wool spots
- Proliferative- new vessel formation. Risk of haemorrhage!
Presentation of diabetic nephropathy
- Most Asx
- Proteinuria
- Measure annually- urine dip, serum creatinine, eGFR
Annual r/v of DM
- HbA1c
- Injection sites
- Albumin:creatinine ratio
- Fundoscopy
- Check feet
- LIpid profile
- U+Es, urine dip
- BP
- BMI
- Education
Management of T1DM
- Lifestyle- good diet, carb counting, courses
- CVS risk control- statin, aspirin, ACEi
- Insulin
- Rapid acting eg novorapid
- Short acting eg actrapid
- Intermediate eg isophane
- Long acting eg glargine
- Mixed eg novomix
- Regimes eg basal-bolus
- Changes in insuline dose- increase by 10%, decrease by 20%
Management of T2DM
- Lifestyle
- Manage glucose:
- Metformin (gliclazide if thin/ poor renal function)
- Metformin + gliclazide (or gliptin/ pioglitazone)
- Metformin + gliclazide + gliptin/pioglitazone
- Insulin
- Manage BP- ACEi
- Manage lipids + CVS risk- Statins, aspirin
- ID + manage complications
What is Cushing’s syndrome and how might it present?
- ++ Cortisol. Loss of -ve feedback.
- Presentation:
- Buffalo hump
- Moon face
- Central obesity
- Proximal muscle wasting
- Plethora, bruising, striae
- Osteoporosis
- Skin/ muscle atrophy
- Gynaecomastia
- Mood change
Causes of Cushing’s Syndrome
- ACTH Dependent (raised):
- Cushing’s disease- piuitary adenoma.
- Ectopic ACTH eg SCLC. Sx- hyperpigmentation, weight loss, hyperglycaemia, hypokalaemia, metabolic alkalosis
- Ectopic CRF production (thyroid/ prostate Ca)
- ACTH Independent (Low):
- Adrenal adenoma
- Adrenal nodular hyperplasia
- Iatrogenic **steroids**
Ix of Cushing’s syndrome
- Confirm cushing’s- raised serum cortisol
- Low dose dexamethasone- Cushing’s = no suppression of cortisol.
- 48h cortisol suppression test:
- Cushing’s disease suppresses with 8mg –> pituitary MRI
- Ectopic ACTH/ adrenal adenoma not suppressed.
- Plasma ACTH
- Undetected= adrenal tumour –> CT
- Detectable = cushing’s disease/ ectopic ACTH. Do 48h suppression.
What is Addison’s Disease and what might cause it?
- Addison’s= destruction of adrenal cortex –> reduced cortisol and aldosterone
- Primary= Addison’s disease. Destruction of adrenals –> no production of mineralo/glucocorticoids
- Secondary= Common. Iatrogenic due to long term steroids. Present in crisis after removal of steroids
- Causes: AI, TB, adrenal mets, opportunistic infection, adrenal haemorrhage, late onset congenital
Presentation of Addison’s Disease
- Mood change
- Tired + tearful
- Weight loss/ anorexia
- Tanned
- Myalgia/ arthralgia/ weakness
- Hypogonadal
- Changed distribution of body hair
- GI disturbance- abdo pain, vomiting
Addison’s Disease Ix
- Bedside- BM (low)
- Bloods- anaemia, hyponatraemia, hyperkalaemia, hypercalcaemia, uraemia, eosinophilia, autoantibodies, plasma renin-aldosterone
- Imaging- AXR/CXR ?TB ?acute abdo
- Special- short synacthen test:
- Plasma cortisol before and 30mins after 250 micrograms tetracosactide
- Addison’s exclused if 30 min cortisol >550 nmol/L
Management of Addison’s Disease
- Replace steroids!
- 15-25mg hydrocortisone (+5-10 before exercise)
- 50-200 micrograms fludrocortisone
- Double steroids in febrile illness/ injury/ stress
- Don’t stop abruptly!
- Give steroid card
- Follow up annually. BP, U+Es, look for AI disease
Causes and presentation of Addisonian Crisis
- Causes- infection/ trauma/ dehydration/ shock in someone with Addison’s. Missed steroid in someone on long term.
- Presentation:
- Intense fatigue/ weekness
- Nausea ++
- Confusion, headache, dizziness
- Low GCS/ coma
- Hypotension
- Hypoglycaemia
- ?Hyperkalaemia + hyponatraemia
Ix and Tx of Addisonian Crisis
- Don’t delay Tx if suspect!
- Ix: Bloods- cortisol, ACTH, U+Es, glucose, cultures
- Tx:
- ABCDE + IVT resus
- HYDROCORTISONE 100MG IV STAT –> PO after 72h
- ?Fludrocortisone if adrenal disease
- ?Glucose
- Tx the cause
What is hyperaldosteronism, what causes it and how might it present?
- = excess aldosterone production –> Na+ and water retention
- Causes: Adrenal adenoma (conn’s), adrenal hyperplasia.
- Presentation:
- Thirst ++
- Polyuria
- Weakness
- Muscle spasms
- Headaches
- Hypertenison (in young, refractory)
Ix and Tx of primary hyperaldosteronism
- Ix-
- U+Es (hypokalaemia, hypernatraemia)
- ABG (metabolic alkalosis)
- Plasma renin:aldosterone (high ald, low renin)
- Tx:
- Spironolactone 200-300mg/24h PO
- ?Surgical resection of adenoma
What causes secondary hyperaldosteronism?
- Renal hypoperfusion
- Eg diuretics, HF, liver failure, renal artery stenosis
- Presents similarly, renin:aldosterone not high
- Tx- spironolcatone, ACEi
What is a phaeochromocytoma and what causes it?
- = Excess catecholamine (noradrenaline) release from the adrenal medulla.
- Caues= usually adrenal tumour. Rarely paraganglioma.
Presentation of phaeochromocytoma
- Triad: Epidodic headache, tachycardia, sweating.
- Other Sx:
- Episodic hypertension
- Anxiety
- Facial flushing
- Chest tightness
- SOB
- Tremor
- Palpitations
- Abdo pain + vomiting
Ix and Tx of Phaeochromocytoma
- Ix
- Bedside- 24h urine collection for creatinine, catecholamines, metanephrines.
- Bloods- serum metanephrines
- Imaging- CT abdo
- Special- Genetic testing
- Lifelong malignancy screening.
- Tx:
- Alpha blockers (phenoxybenzamine) –> beta blockers (propranalol)
- Surgical resection of tumour
What is acromegaly and how might it present?
- = Excess growth hormone secretion from pituitary tumour/ hyperplasia
- Large hands/ feet
- Coarse facial features
- Jaw protrusion
- Headaches +/- bitemporal hemianopia
- Macroglossia
- Hyperglycaemia
- Hypertenison
- Sweating
Ix and Tx of acromegaly
- Ix
- Bedside- ECG, BM, visual fields, BMI
- Bloods- IGF-1, glucose, calcium, phosphate
- Imaging- MRI pituitary
- Special- OGTT
- Tx
- Pituitary tumour resection
- Octreotide
- Pegvisomant
Complications of acromegaly
- DM
- Vascular- HTN, LVH, cardiomyopathy, arrhythmias, CVA, IHD
- Neoplasia- colon
What hormones are produced by the pituitary?
- Ant. Pituitary
- TSH
- ACTH
- GH
- Prolactin
- LH
- FSH
- Post. Pituitary
- ADH
- Oxytocin
Causes of Hypopituitarism
- Hypothalamus- Kallman’s, tumour, inflammation, infection, ischaemia
- Pituitary stalk- Trauma, surgery, mass lesion, meningioma, carotid arty aneurysm
- Pituitary- Tumour, irradiation, inflammation, AI, infiltration (mets, haemachromatosis), ischaemia (apoplexy, Sheehan’s, DIC)
What is Pituitary apoplexy, how might it present and how should it be treated?
- = Rapid pituitary bleed and enlargement.
- Sx- acut headache, meningism, low GCS, ophthalmoplegia, visual field defect
- Tx= urgent hydrocortisone 100mg IV
What is Kallman’s syndrome?
- Loss of GRH
- Colour blindness
- Anosmia
- Hypopituitarism
Presentation, Ix and Tx of Hypopituitarism
- Presentation depends on hormone- GH, FSH/LH, hypothyroidism, adrenal insufficiency, prolactin
- Ix:
- Bloods- LH, FSH, LSH, testosterone, oestradiol, cortisol, IGF-1, U+Es
- Short synacthen
- Imaging- MRI
- Tx- Hydrocortisone, replace other hormones
What is Diabetes Insipidus, what causes it, and how might it present?
- = Failure to concentrate urine due to lack of ADH (neurogenic) or lack of renal respone (nephrogenic).
- Causes:
- Neurogenic- Idiopathic, traum, tumour/ mets, infection, haemorrhage
- Nephrogenic- Lithium, CRF, post-obstructive uropathy
- Presentation- Polydipsia ++, polyuria, diluted urine, dehydration
Ix and Tx of Diabetes Insipidus
- Ix:
- Bedside- urine osmolality
- Bloods- U+Es, calcium, glucose, serum osmolality
- Water deprivation test- don’t drink water, monitor weight, fluid balance, urine+plasma osmolality over 8 hours
- –> DI = failure to concentrate urine (<600mOsmol/Kg).
- –> Give desmopressin –> concentrated in neurogenic not nephrogenic
- Tx: Tx cause!
- Neurogenic- desmopressin
- Nephrogenic- bendroflumethiazide, NSAID
Causes and presentation of hypokalaemia
- Hypokalaemia= <3.5mmol/L
- Intake- diet, IVT (need 1mmol/kg/hr)
- Excretion- D+V, sweating, diuretics, Cushing’s Conn’s, renal (eg gittleman’s)
- Intracellular shift- Alkalosis, insulin, salbutamol
- Presentation- weakness, cramps, nausea, palpitations
Ix and Tx of hypokalaemia
- Ix:
- ECG- flatted T waves, arrhythmias
- U+Es (inc Mg)
- ABG- ?alkalosis
- Tx: (emergency = <2.5mmol/L)
- ABCDE
- Continuous ECG
- Access and bloods
- Replace 40mmol/L KCl in 1L 0.9 NaCl
- ABG
- Senior r/v
- Non-emergency- Sando K, Mg replacement, 20-40mmol/L KCl
Causes and presentation of hyperkalaemia
- Hyperkalaemia= K+ >5.3 mmol/L
- Intake- IVT
- Excreation- Renal failure, Addison’s, spironolactone, amiloride, ACEi
- Extracellular shift- Metabolic acidosis, non-selective Beta blockers, low insulin, tissue necrosis
- Presentation- Palpitations, chest pain, dizziness
Ix and Tx of Hyperkalaemia
- Ix:
- ECG- tall tented t waves –> broad QRS –> VF
- U+Es
- ABG- acidosis
- Tx: Emergency= >7mmol/L
- ABCDE + ECG
- Access and bloods- U+Es
- 10mL 10% calcium gluconate over 2 mins
- 10 units actrapid in 50mL 50% glucose over 10 mins
- 5mg salbutamol NEBS
- ABG
- Senior r/v
- Non-emergency- furosemide, ?dialysis. Stop nephrotoxic drugs
Presentation of hyponatraemia
- Anorexia
- Nausea
- Malaise
- Headache
- Irritability
- Confusion
- Weakness
- Low GCS (cerebral oedema)
- Seisures
- ?HF/ Oedema
Causes of hyponatraemia
- Hypovolaemic:
- Urine Na+ >20mmol/L = renal loss. Addison’s, diuretics, salt losing nephropathy
- Urine Na+ <20mmol/L= non-renal loss. D+V, burns, SBO, heat
- Hypervolaemia- nephrotic syndrome, HF< liver cirrhosis, renal failure
- Euvolaemia:
- Urine osmolality >100mmol/kg= Water overload, hypothyroid
- <100mmol/kg = SIADH
What is SIADH and how is it diagnosed?
- Syndrome of Inappropriate ADH secretion from hypothalamus –> hyponatraemia
- Diagnosis
- Urine concentrated (osmolality >500mOsmol/kg), dilute plasma (<275mOsmol/kg)
- No recent diuretics
- Euvolaemic
- Urine sodium >20mmol/L
- Normal adrenal and thyroid function.
Causes of SIADH
- Malignancy- lung, pancreas, lymphoma
- Lung/ CNS infection
- Vascular events
- Drugs- SSRIs, TCAs, carbamazepine, antipsychotics
- Idiopathic
Treatment of hyponatraemia
- Correct fluid and Na+ at same rate lost (ie usually slowly)
- Na+ rise no more than 10mmol/l/24h (risk of osmotic demyelination)
- Acute- seizures/ coma or Na+ <120mmol/l –> rapid replacement with hypertonic saline 5mmol/L
- Chronic Asx- fluid restriction +/- domecloclyline
- Stop diuretics + NSAIDs
- Hypovolaemia- replace lost fluid with 0.9% NaCl
Causes and presentation of hypernatraemia
- Causes:
- Fluid loss- D+V, burns, DI, DM, Conn’s
- ++ Na+- IVT, Conn’s
- Presentation:
- Thirst
- Weakness/ lethargy
- Irritability
- Confusion
- Seizures/ Coma
- Signs of dehydration
Ix and Tx of Hypernatraemia
- Ix:
- Urine osmolality (>400mOmol/kg = fluid loss)
- Plasma osmolality
- ?CT/ MRI if ?central cause
- Tx:
- Slow correction
- Hypovolaemia- 0.9% NaCl 1L/6h
- Normovolaemic- PO fluids/ 5% glucose 1L/6h
Presentation of hypercalcaemia
- Stones - renal stones
- Bones - pain, osteoporosis, osteopoenia, arthritis
- Groans - abdo pain, D+V, constipation, weight loss
- Psychiatric Moans - depression, confusion
- Thrones - polyuria + polydipsia
- Signs- dehydration, arrhythmias, cachexia, HTN
Causes of hypercalcaemia
- Hyperparathyroidism- Primary (adenoma), tertiary (prolonged secondary and hyperplasia)
- Malignancy- Boney mets, myeloma, AML, ALL, ectopic PTH-related peptide (SCLC, endometrial, breast, ovarian, renal)
Ix and Tx of hypercalcaemia
- Bedside- ECG, urine electrophoresis
- Bloods- FBC, U+Es, Mg2+, Ca2+, PO43-, ALP, PTH, ESR, serum electrophoresis
- Hyperparathyroidism- High calcium + PTH
- Multiple myeloma- High calcium, high serum albumin
- ALL- High calcium and phosphate
- AML- variable calcium levels
- Ectop PTH-r peptide- High calcium, low phosphate, variable albumin
- Imaging- CXR, bone scan
- Tx- IVT, bisphosphonates eg Zolendronic acid
Presentation of Hypocalcaemia
SPASMODIC
- Spasms
- Perioral tingling
- Anxious/ depressed
- Seizures
- Muscle tone (tetany + hyperreflexia)
- Orientation impaired (confusion)
- Dermatitis
- Impetigo herpetiformis
- Chvostek’s + cardiomyopathy
- Others: arrhythmias, bradycardia/hypotension
What are Trousseau’s and Chvostek’s signs and what do they indicate?
- Trousseau’s= spasm of hand when inflating BP cuff
- Chvostek’s= Unilateral twitching of face from tapping facial nerve
- = Hypocalcaemia
What are the causes of hypocalcaemia?
- Vitamin D deficiency:
- Malabsorption- Coeliac, CF, short bowel
- Lack of sunlight
- Renal disease
- Hyperventilation
- Hypomagnesia:
- Drug induced- PPI, loop + thiazide diuretics, alcohol
- Malabsorption- laxative abuse, crohn’s, UC, coeliac, short gut
- Hypoparathyroidism- Post-surgical, Di-George
Ix and Tx of hypocalcaemia
- Ix:
- Bedside- ECG (arrhythmias)
- Bloods- U+Es, calcium, phosphate, magnesium, albumin, ALP, PTH, Vit D
- Tx:
- Hypoparathyroid- Acute= IV calcium gluconate. Chronic- PO calcium + calcitrol (vit D)
- Hypomagnesia- Acute= IV magnesium sulphate replacement +/- IV calcium gluconate . Chronic- PO magnesium oxide
Causes, Sx and Tx of Hypophosphataemia + Hyperphosphataemia
Hypo
- Causes- Vit D def, alcohol withdrawal, refeeding syndrome, starvation, hyperparathyroidism, DKA
- Sx: Muscle weakness, rhabdomyolysis, cardiac arrest, arrhythmias
- Tx: PO/IV phosphase supplement
Hyper causes- CKD Tx with phosphate binders, tumour lysis
Caues, Sx and Tx of hypomagnesaemia/ hypermagnesaemia
Hypo
- Causes- diuretics, diarrhoea, ketoacidosis, alcohol, parenteral nutrition
- Sx- Paraesthesia, seizures, tetany, arrhythmias
- Tx= magnesium salts
Hyper
- Renal failure, excessive antacids.
- Sx- low bp/ hr, hyporeflexia, CNS/resp depression, coma
- Tx only severe >7.5