Hypercalcemia - Meran

Question 1

What does low potassium cause in the heart?

Answer 1

VF

Question 2

What does high potassium cause in the heart?

Answer 2

Asystole

Question 3

Symptoms of hypercalcemia

Answer 3

BONES - bony pain
MOANS - depression
GROANS - renal stones, pancreatitis, pain
STONES - renal stones

Band keratopathy
Polyuria and polydipsia

Question 4

Symptoms of hypocalcemia

Answer 4

CATS go numb

tetany
arrhythmia
numbness

Question 5

Case 1 - a patient comes in with depression, smith’s fracture and haematuria. What’s going on?

Answer 5

Hypercalcemia - 2.82 (2.20-2.60)

Question 6

What is a key investigation for hypercalcemia?

Answer 6

Plasma calcium levels
PTH levels

Question 7

Three key causes of hypercalcemia -

Answer 7

Primary hyperparathyroidism (community)
Cancer (hospital)
Sarcoidosis

Question 8

Smith’s vs Colle’s fracture

Answer 8

Colles = FOOSH, distal radius (literally the bit touching the wrist) is displaced posteriorly (DR CPD)
Smith = fall onto back of hand, distal radius has VOLAR displacement aka towards the palm

Question 9

What does volar mean?

Answer 9

Towards the palm

Question 10

What is another name for the skeletal changes which occur in primary hyperparathyroidism?

Answer 10

Osteitis fibrosa et cystica

Question 11

How do you investigate renal colic?

Answer 11

Non contrast CT KUB
or USS if someone is pregnant or a child

+ urinalysis
+ urea and creatinine
+ stone analysis if unclear

Question 12

Which renal stones show up opaque?

Answer 12

Calcium stones

Question 13

Management of renal colic

Answer 13

Lithotripsy
Hydration
Analgesia

cystoscopy? lithotomy?

Question 14

Which stones are radiolucent?

Answer 14

Uric acid - gout

Question 15

How can you prevent renal colic?

Answer 15

Hydration

Thiazide diuretics (if people are stone formers)

Question 16

Vit D metabolism

Answer 16

UV turns cholestrol to 7-dehydroxycholestrol

Liver turns 7-dehydrocholestrol / D3/cholecalciferol into 25-hydroxycholecalciferol using 25 hydroxylase; this is through first pass metabolism.

Kidney converts this into 25-vitamin D3 into 1,25 vitamin D3 through 1 alpha hydroxylase. This is a rate limiting step.

Question 17

Which step is rate limiting in vit D metabolism?

Answer 17

1 alpha hydroxylase step - kidney

Question 18

What is another name for calcidiol?

Answer 18

25 hydroxyl cholecalciferol / 25-Vit D3

Question 19

What is another name for calcitriol?

Answer 19

1,25 hydroxy cholecalciferol

Question 20

Where does PTH act in the metabolism of vitamin D?

Answer 20

PTH stimulates the 1 alpha hydroxylase enzyme, produced by the kidneys.

Question 21

What level of calcium is considered really bad hypercalcemia?

Answer 21

Above 3.0mmol/L

Question 22

What symptoms might someone with severe hypercalcemia present with?

Answer 22

Confusion
Drowsiness
Seizures
Renal failure
Dehydration

Question 23

How do you manage hypercalcemia in an emergency?

Answer 23

Get IV access - cannula or central line (through subclavian)

Calciuresis:
0.9% saline 4L
Furosemide

Keep hydrated

Arrange for surgery

Question 24

How long does it take for the emergency treatment of hypercalcemia to work?

Answer 24

A few days - gotta be patient

Question 25

What can be used as a last resort? What is the side effect of this?

Answer 25

Bisphosphonates - e.g. IV pamidronate 30-60mg. However then this locks into the bone and causes hypocalcemia when the patient has their parathyroid glands removed.

Question 26

What are Looser's zones?

Answer 26

caused by vit D deficiency; pseudofractures (not to do with primary hyperparathyroidism)

Question 27

What would a hand x-ray show in hypercalcemia?

Answer 27

Radial aspect always shows cystic changes.

Question 28

Bilateral hilar lymphadenopathy

Answer 28

Sarcoidosis TB

Question 29

What would the histology show

Answer 29

Multinucleate giant cells

Question 30

Why does sarcoidosis cause hypercalcemia?

Answer 30

Macrophages in giant cells PRODUCE 1 alpha hydroxylase so they convert 25-OH vitamin D3 into 1,25-OH vitamin D, which then acts on the bone and gut to move more calcium into the blood.

Question 31

What does histology of sarcoidosis show?

Answer 31

Giant multinucleated cells

Question 32

How do you treat sarcoidosis?

Answer 32

Prednisolone - treats both the lung symptoms and the sarcoidosis

Question 33

What's the side effect of prednisolone?

Answer 33

Hyperglycemia, cushings syndrome, thin skin, easy bruising etc

Question 34

Why does cancer cause hypercalcemia?

Answer 34

Some cancers produce PTHrP which makes the cancers invade bone more easily

Question 35

How do you treat cancer hypercalcemia?

Answer 35

Fluids + bisphophonate

Question 36

How do bisphosphonates work in cancer hypercalcemia

Answer 36

Osteoblasts make bone with bisphosphonate. However bisphosphonate is resistant to osteoclast activity (stimulated by PTHrP from cancer) so it reduces the pain from bony mets.