hypercalcemia and related disorders Mnemonics Flashcards
What does ‘PTH High’ indicate in hypercalcemia diagnostics?
Primary hyperparathyroidism (PHPT)
Indicates a condition where the parathyroid gland is overactive, leading to elevated calcium levels.
What does ‘PTH Low’ signify in the context of hypercalcemia?
Malignancy (PTHrP), granulomas (1,25(OH)₂D₃), vitamin D excess
Suggests that other causes, such as cancers or vitamin D toxicity, are influencing calcium levels.
Which conditions are associated with ‘PTH Mid’ levels?
Lithium effect, Familial hypocalciuric hypercalcemia (FHH)
These conditions can lead to ambiguous PTH levels, complicating diagnosis.
What mnemonic is used to categorize types of malignancy-related hypercalcemia?
P-L-O-T
Represents PTHrP-mediated, Local osteolysis, 1,25(OH)₂D₃, and True ectopic PTH.
What does the treatment ladder ‘3-2-1 Protocol’ involve?
Within 3 hours:
* IV fluids (NS at 200-300 mL/hr)
* Calcitonin 4 IU/kg IM
Within 2 days:
* Zoledronate 4 mg IV or pamidronate 60-90 mg IV
Within 1 week:
* Address underlying cause
* Start denosumab if bisphosphonates fail
A structured approach to manage severe hypercalcemia in a clinical setting.
What are the urine calcium rules for differentiating FHH from PHPT?
FHH:
* Urine Ca <100 mg/24h
* Ca/Cr clearance ratio <0.01
* Family history present
PHPT:
* Urine Ca >250 mg/24h
* Ca/Cr clearance ratio >0.02
* No family history
Important for avoiding unnecessary surgeries such as parathyroidectomies.
What does the mnemonic ‘VITAMIN D’ represent in granulomatous causes of hypercalcemia?
V - Vasculitis (rare)
I - Infections (TB, histo, coccidio)
T - Talc/silicone exposure
A - AIDS-related
M - Mycobacterial
I - Idiopathic (sarcoid)
N - Neoplasms (lymphoma)
D - Drugs (BCG, interferon)
Useful for identifying various conditions that can lead to elevated calcium levels.
What are the red flags for Milk-Alkali Syndrome represented by the mnemonic ‘CASH’?
C - Calcium supplements
A - Alkalosis (HCO₃ >30)
S - Serum Cr elevated
H - History of dyspepsia/PPI use
Helps in recognizing this syndrome in emergency presentations.
What ECG changes are associated with hypercalcemia?
Short QT, Tall T, Wide QRS
* Short QT interval (<300ms)
* Peaked T waves
* QRS widening
* PR prolongation
Critical findings that indicate a risk of arrhythmias.
What precautions should be taken when administering bisphosphonates, summarized by ‘RENAL’?
R - Renal function check (eGFR <35 reduce dose)
E - Electrolytes normal (correct hypocalcemia first)
N - No dental work (risk of ONJ)
A - Administer over 15-30 min (zoledronate)
L - Limit to 1 dose/month
Important for safe administration of bisphosphonates to avoid complications.
What are the symptoms of hypercalcemia summarized by ‘Stones, Bones, Groans, Moans, Thrones, Psychiatric Overtones’?
Stones - Kidney stones
Bones - Bone pain/fractures
Groans - GI symptoms (nausea, constipation)
Moans - Fatigue/malaise
Thrones - Polyuria (nephrogenic DI)
Psychiatric overtones - Confusion, depression
These symptoms help clinicians identify hypercalcemia in patients.
What are the primary lab findings in primary hyperparathyroidism?
High calcium
Low phosphate
High PTH
Essential for diagnosing primary hyperparathyroidism.
What does the mnemonic ‘ABCDE’ represent in the treatment approach for hypercalcemia?
A - Aggressive IV fluids
B - Bisphosphonates
C - Calcitonin
D - Discontinue offending drugs
E - Eliminate calcium intake
A structured approach to managing hypercalcemia effectively.
What does the mnemonic ‘CHIMPANZEES’ stand for in causes of hypercalcemia?
C - Calcium supplements
H - Hyperparathyroidism
I - Immobilization
M - Malignancy
P - Paget’s disease
A - Addison’s disease
N - Neoplasms
Z - Zollinger-Ellison syndrome
E - Excess vitamin D or A
E - Endocrine disorders
S - Sarcoidosis/granulomatous diseases
A comprehensive list of potential causes of hypercalcemia.
True or False: Calcitonin works in hours, while bisphosphonates work in days.
True
Important to consider when treating severe cases of hypercalcemia.
What is the significance of the statement ‘FHH is benign but looks like PHPT’?
Genetic testing prevents unnecessary surgery
Highlights the importance of differentiating between familial hypocalciuric hypercalcemia and primary hyperparathyroidism.
Fill in the blank: ‘PTHrP mimics ______ but kills vitamin D.’
[PTH]
Explains the biochemical relationship between PTHrP and vitamin D metabolism.
What does the mnemonic CHIMPANZEES represent in relation to hypercalcemia causes?
C - Calcium supplements (milk-alkali syndrome)
H - Hyperparathyroidism (primary/tertiary)
I - Immobilization
M - Malignancy (PTHrP, bone metastases)
P - Paget’s disease
A - Addison’s disease
N - Neoplasms (lymphoma, myeloma)
Z - Zollinger-Ellison (MEN-1)
E - Excess vitamin D/A
E - Endocrine (hyperthyroidism)
S - Sarcoidosis/granulomas
Best for quickly recalling differential diagnosis during clinical rounds or exams
What are the symptoms of hypercalcemia represented by the mnemonic Stones, Bones, Groans, Moans, Thrones, Psychiatric Overtones?
- Stones - Nephrolithiasis
- Bones - Osteoporosis/pain
- Groans - GI (nausea, constipation)
- Moans - Fatigue/malaise
- Thrones - Polyuria (nephrogenic DI)
- Psychiatric - Confusion, depression
Best for recognizing hypercalcemia presentations
What are the classic lab findings in primary hyperparathyroidism represented by the mnemonic High-Low-High?
- High calcium
- Low phosphate
- High PTH
Best for classic lab findings in primary hyperparathyroidism
What does the mnemonic PLOT represent in the context of malignancy mechanisms causing hypercalcemia?
- P - PTHrP (humoral)
- L - Local osteolysis
- O - 1,25(OH)₂D₃ (lymphomas)
- T - Tumor ectopic PTH
Best for categorizing cancer-related hypercalcemia
What are the granulomatous causes of hypercalcemia represented by the mnemonic STAR?
- S - Sarcoidosis
- T - Tuberculosis
- A - AIDS-related
- R - Rheumatoid nodules
Best for remembering granuloma-associated hypercalcemia
What are the treatment steps for hypercalcemia represented by the mnemonic ABCDE?
- A - Aggressive IV fluids
- B - Bisphosphonates
- C - Calcitonin
- D - Discontinue triggers
- E - Eliminate calcium intake
Best for acute management steps
What are the key differences between FHH and PHPT?
- FHH:
- Familial
- Hypocalciuria (Ca/Cr <0.01)
- High Mg²⁺
- PHPT:
- Primary
- Hypercalciuria (Ca/Cr >0.02)
- PTH elevated
Best for differentiating these similar conditions
What is the Milk-Alkali syndrome triad represented by the mnemonic ABC?
- A - Alkalosis
- B - BUN elevated
- C - Calcium high
Best for remembering the classic triad
What does the mnemonic PTH-PO₄-Urine represent in the diagnostic triad for hypercalcemia?
- High PTH + Low PO₄ + High Urine Ca = Primary hyperparathyroidism
- Low PTH + Low PO₄ + High PTHrP = Malignancy (humoral)
- Low PTH + High 1,25(OH)₂D₃ = Granulomatous disease
- Normal PTH + Low Urine Ca = FHH
Clinical pearl: Always check ionized calcium if albumin is abnormal
What does the mnemonic 4 M’s represent for malignancy-related hypercalcemia?
- M - Metastatic bone destruction
- M - Mediated by PTHrP (humoral)
- M - Macrophage activation (lymphomas)
- M - Mineral dysregulation (ectopic PTH)
Best for oncology boards or tumor boards
What are the treatment timelines for hypercalcemia represented by the mnemonic 0-6-24-72?
- 0 hours: IV NS bolus (20 mL/kg), cardiac monitoring if Ca >13 mg/dL
- 6 hours: Calcitonin 4 IU/kg IM (repeat q12h), furosemide ONLY if volume overloaded
- 24 hours: Zoledronate 4 mg IV (or pamidronate 60-90 mg), correct hypokalemia/hypomagnesemia
- 72 hours: Denosumab if bisphosphonates fail, dialysis if Ca >14 mg/dL with renal failure
ER protocol: This sequence prevents rebound hypercalcemia
What granulomatous diseases are represented by the mnemonic SACHED?
- S - Sarcoidosis
- A - AIDS (disseminated infections)
- C - Coccidioidomycosis (bone resorption)
- H - Histoplasmosis
- E - Exposure (beryllium, silicone)
- D - Drugs (BCG, interferon-γ)
Key point: Steroids work for all except coccidioidomycosis
What are the surgical criteria for PHPT represented by the mnemonic SCAN?
- S - Symptoms (stones, bones)
- C - Calcium >1 mg/dL above ULN
- A - Age <50
- N - Nephrolithiasis/nephrocalcinosis
Updated guideline: Asymptomatic patients may not need surgery
What are the findings in Milk-Alkali Syndrome represented by the mnemonic ABC?
- A - Alkalosis (pH >7.45)
- B - BUN/Cr ratio >20:1
- C - Calcium supplements history
Modern variant: Calcium carbonate + PPIs
What ECG findings are represented by the mnemonic QT-SHORT?
- Q - QRS widening (>120ms)
- T - T wave peaking
- S - ST segment shortening
- H - Heart block risk
- O - Osborn waves (severe cases)
- R - Rhythm disturbances (VT/VF)
- T - Torsades (with hypokalemia)
Critical sign: QRS >140ms requires emergent calcium-lowering
What precautions should be taken when administering bisphosphonates represented by the mnemonic BONE?
- B - Baseline creatinine mandatory
- O - Oral hygiene (risk of ONJ)
- N - Normal calcium before infusion
- E - Electrolytes balanced (K⁺, Mg²⁺)
Safety tip: Hydrate with 500 mL NS pre-infusion
True or False: PTH tells the story in hypercalcemia diagnosis.
True
High PTH = Primary hyperparathyroidism; Low PTH = Look for malignancy/granulomas
True or False: FHH is benign and requires treatment.
False
FHH is familial, benign, and needs no treatment. Genetic testing prevents unnecessary surgery.
Fill in the blank: Calcitonin works in ______, bisphosphonates in ______.
hours; days
Use together for Ca >13 mg/dL
What is a key point regarding steroids in granulomatous disease?
Steroids are diagnostic and therapeutic
Trial in suspected granulomatous disease
What should be checked before surgical intervention in hypercalcemia?
Check urine calcium
Essential to distinguish FHH from PHPT
What does the acronym MENU stand for in PTH-Dependent Hypercalcemia?
M - MEN syndromes (1 > 2A)
E - Ectopic PTH (extremely rare)
N - Neonatal severe HPT
U - Urine calcium low? Think FHH
Always screen for MEN1 in young PHPT patients (pancreatic NET, pituitary tumors)
What causes PTH-Independent Hypercalcemia as represented by the acronym D-VITALS?
D - D vitamins (intoxication)
V - Vasoactive (PTHrP tumors)
I - Inflammatory (granulomas)
T - Thiazides/Thyrotoxicosis
A - Addison’s (rare)
L - Lithium/Lymphoma (calcitriol)
S - Sarcoid/Silicone
Check 24,25(OH)₂D₃ to distinguish true vitamin D toxicity
What are the components of the PHPT Workup represented by the acronym PALMS?
P - Parathyroid ultrasound + Sestamibi
A - Alkaline phosphatase (bone turnover)
L - Lithogenic profile (24h urine Ca/Cr, citrate)
M - MEN1 gene if <40 y/o
S - Skeletal survey (vertebral fractures, DXA)
Always rule out thyroid nodules pre-parathyroidectomy
What are the medical management options for hypercalcemia represented by the acronym CINE-BED?
C - Cinacalcet (CaSR modulator)
I - IV bisphosphonates (zoledronate preferred)
N - No calcium restriction (PHPT)
E - Estrogen analogs (raloxifene)
B - Bone monitoring (q6-12mo DXA)
E - Eucalcemic diet (avoid extremes)
D - Denosumab (if bisphosphonate failure)
Vitamin D repletion may lower PTH in PHPT (maintain 25(OH)D >20 ng/mL)
What is the 3D Approach in MEN1 Hyperparathyroidism?
D - Debulking (subtotal vs. total PTX)
D - Durable monitoring (annual Ca/PTH)
D - Dual pathology (check for gastrinomas)
Intraoperative PTH monitoring is mandatory (50% drop at 10 mins)
What are the clues for diagnosing FHH represented by the acronym CLUES?
C - Calcium mildly elevated (usually <11 mg/dL)
L - Low urine calcium (<100 mg/24h)
U - Unaffected relatives (50% penetrance)
E - Elevated Mg²⁺ (unlike PHPT)
S - Stable lifelong course
Diagnostic gold standard: CaSR gene testing
What does the Li-PTH Axis represent in Lithium-Induced HPT?
L - Left-shifted Ca-PTH curve
i - Increased set point for Ca suppression
P - Parathyroid hyperplasia
T - Treatment: Cinacalcet > surgery
H - High recurrence if PTX done
Check calcium q3mo in chronic users
What are the components of tertiary HPT Post-Renal Tx represented by the acronym STOP?
S - Sestamibi for localization
T - Target PTH <2x ULN
O - Osteoporosis management
P - Parathyroidectomy if:
- Ca >11.5 mg/dL × 6mo
- Vascular calcification
- Pruritus/calciphylaxis
3.5 gland removal preferred
What is ‘Hungry bone syndrome’ in relation to postoperative care?
Expect profound hypocalcemia post-PTX in severe osteitis fibrosa (have IV calcium ready)
This condition can occur after parathyroidectomy due to rapid bone mineralization.
True or False: PTHrP and PTH are the same.
False
Order intact PTH and PTHrP simultaneously to avoid assay cross-reactivity.
What is required for diagnosing ‘Non-classical PHPT’?
3 elevated PTH measurements + exclude causes
This variant presents with normal calcium levels.
What should be done in a genetic testing cascade for FHH?
Screen all FHH probands’ families for CaSR mutations
This helps in identifying at-risk individuals.
What is the recommendation for PHPT with eGFR <60?
May benefit from early surgery regardless of symptoms
Early intervention can prevent complications related to hyperparathyroidism.
