Hypercalcaemia

Question 1

What are the causes of Hypercalcaemia?

Answer 1

Causes:
Common - Malignancy (Myeloma/Mets), Hyperparathyroidism
Others - Hyperthyroidism, Vitamin D supplements, Thiazide Diuretics, Dehydration, Sarcoidosis, Ectopic PTHRP release (E.g. Squamous Cell lung cancer)

Question 2

What will you find in a history of Hypercalcaemia?

Answer 2

Symptoms:
Stones – Renal or Biliary
Bones – Bone Pain
Groans – Abdominal Pain, N and V, constipation, tiredness
Thrones – Polyuria causing dehydration
Psychiatric Overtones - Depression, Anxiety, confusion

Risk Factors:
Cancer
Hyperparathyroidism

Specific Questions to ask:
Do a good systems review
Ask about cancer symptoms like weight loss, appetite loss etc
Bone pain - Bone Cancer
Chronic symptoms suggest hyperparathyroidism but acute suggests malignancy

Question 3

What will you find on examination of Hypercalcaemia?

Answer 3

End of the bed:
Confusion
Coma
Hyporeflexia
Abdomen:
Look for splenomegaly/hepatomegaly indicating leukaemia
Hand:
Arrhythmias

Question 4

What investigations will you order in`Hypercalcaemia?

Answer 4

Investigation’s: First Line differentiating tests are albumin and phosphate
Initial Investigations:
Albumin – Raised (Dehydration), Low (Think Cancer) Normal (Look At phosphate)
Phosphate – Low (Hyperparathyroidism, PTHrp Release), High (Cancer, Hyperthyroidism, Sarcoidosis, Drugs)

Bedside:
ECG - Short QT interval, can mimic MI, Osborn wave
Full set of Observations

Bloods:
LFT (ALP) -raised indicates bone cancer, thyrotoxicosis or sarcoidosis. Low indicates Myeloma, Vit D excess, Alkalosis or sarcoidosis
ABG - Alkalosis associated with cancer
U&E - Low K+ or Cl- associated with cancer
PTH - Raised in hyperparathyroidism but not raised in PTHRP
TFT – Raised in hyperthyroidism
FBC - Looking for any blood cancer changes or anaemia of chronic disease

Imaging:
CXR - Looking for lung cancer
Bone isotope scan

Question 5

What is the treatment of Hypercalcaemia?

Answer 5

Medical:
IV fluids if indicated by fluid status or albumin
Zoledronic Acid (Bisphosphonate) - Reduces bone resorption and thus lower calcium. Single large dose can be use in acute situations or long-term use in chronic
Treat underlying cause

Question 6

What is hypercalcaemia?`

Answer 6

Normal Calcium levels are between 8.5 and 10.2. Any value below 8.5 is hypercalcaemic.
Symptoms can be vague – In general: Calcium Abnormalities  Muscles
Investigate logically – In general: Calcium  Look at Phosphate level? i.e. PTH