Miscellaneous Flashcards
What is the normal range for serum calcium in the body?
2.2 - 2.6 mmol
What are the categories of causes of Hypercalcaemia?
Parathyroid related
Non parathyroid related
What are the parathyroid causes of Hypercalcaemia?
Hyperparathyroidism (primary or tertiary)
What are the non parathyroid related causes of Hypercalcaemia?
Malignancy (myeloma or bony mets)
CKD
Vit D intoxication
Addisons
Drugs
Immobilisation
Familial hypocalciuric Hypercalcaemia
Sarcoidosis
What medications can cause Hypercalcaemia?
Thiazides
Lithium
Cisplatin
What is primary Hyperparathyroidism ?
Tumour of the parathyroid glands leads to uncontrolled production of PTH
What cells produce PTH?
Chief cells
What is the function of PTH?
Increases serum calcium levels:
-inc osteoclast activity (bony resorption)
-inc calcium reabsorption from urine
-inc active vitamin D Levels so more calcium is absorbed from the gut
What is secondary hyperparathyroidism?
When patient has CKD the levels of calcium are low, this stimulates the parathyroid gland to increase its activity to counteract this
How does secondary hyperparathyroidism affect serum calcium levels?
Typically normal (doesn’t become high)
What is tertiary hyperparathyroidism?
When the parathyroid glands undergo hyperplasia from being overactive with Secondary hyperparathyroidism
How does Hypercalcaemia present?
Bones groans thrones stones and psychic moans:
-constipation
-N+V
-renal stones
-fatigue
-depression
-psychosis
-anorexia
What are some complications of Hypercalcaemia?
Renal stones
Osteoporosis
Pancreatitis
Glaucoma
What are important investigations when investigating a Hypercalcaemia?
FBC
U+Es
PTH LEVELS
TFT
Cortisol
Vit D
Myeloma screen
Which investigations is most important for Hypercalcaemia?
PTH levels
Why is it important to measure PTH levels with Hypercalcaemia?
Parathyroid issue or not
If PTH = elevated is parathyroid issue
If PTH not elevated MOST LIKELY MALIGNANCY
When the patients PTH is elevated when they have Hypercalcaemia, what is the next step investigation?
Urinary calcium creatinine clearance ratio
What is the relevance of measuring urinary calcium creatinine clearnce ratio in a patient with Hypercalcaemia whos PTH is elevated?
Determine whether it’s primary hyperparathyroidism or Familial hypocalciuric Hypercalcaemia
What urinary calcium creatinine clearance ratio indicates Familial Hypocalciuric Hypercalcaemia?
LOW RATIO/ low calcium in urine
What urinary calcium creatinine clearance ratio indicates primary hyperparathyroidism?
High ratio/ lots of calcium in urine
When a patient has Hypercalcaemia and their PTH is not elevated, what are you thinking and what imaging would you use?
? Malignancy
CT CAP
Also could image parathyroid
What is the treatment for Hypercalcaemia caused by familial hypocalciuric Hypercalcaemia?
Doesn’t require treatment
What is the gold standard treatment for a patient with Hypercalcaemia caused by primary hyperparathyroidism?
Parathyroidectomy / surgical removal of adenoma
What is the criteria for treating a patient with Hypercalcaemia caused by primary hyperparathyroidism with a parathyroidectomy?
Ca2+ > 3mmol
Age < 50
T score < -2.5
What investigation would you need to do so you can work out if a patient is eligible for a parathyroidectomy with primary hyperparathyroidism?
DEXA scan for T score
If a patient is not eligible for a parathyroidectomy when they have Hypercalcaemia what is the next most suitable options?
Medication
What medication can be given for second line treatment for Hypercalcaemia caused by primary hyperparathyroidism?
Cinacalcet
+
Bisphosphonates and or HRT
What is considered emergency Hypercalcaemia?
Ca2+>3.5mmol
What is the treatment for emergency Hypercalcaemia?
Vigorously hydrate 200-500ml/hr (3-6L over 24hrs)
Once volume depleted give bisphosphonates
What is considered hypocalcaemia?
Ca2+ < 2.2mmol
What are the categories off causes of Hypocalcaemia?
Parathyroid related
Non parathyroid related
What are the parathyroid causes of Hypocalcaemia?
Hypoparathyroidism
Iatrogenic Hypoparathyroidism (Surgery, radiation, infiltration)
What are the non parathyroid related causes of Hypocalcaemia?
Vitamin D deficiency
CKD
Magnesium deficiency
GI absorption issues (coeliacs, Crohns)
Drugs
Osteoblastic metastases (prostate)
What drugs can cause hypocalcaemia?
Calcitonin
Cisplatin
Phosphate
Citrates
How does Hypocalcaemia present?
Seizures
Cramps
Tingling/numbness
Tetany
Strider
What are the 2 signs that indicate Hypocalcaemia?
Chvosteks sign
Trousseaus sign
What is chvosteks sign?
Tapping on the facial muscles causes Ipsilateral twitching of the facial muscle
Indicate hypocalcaemia
What is Trosseaus sign?
Inflate blood pressure cuff 20mmHg over their systolic blood pressure for 2-3 mins
If positive, the wrist will flex/carpopedal spasm will occur (tetany)
Sign of Hypocalcaemia
How do you investigate a patient with Hypocalcaemia?
FBC
U+E + urine dip
PTH LEVELS
Vit D levels
Amylase
Mg levels
How do you manage hypocalcaemia?
Calcium supplements
Keeping calcium below normal range
Vitamin D supplements
Why do you keep calcium just bellow normal range in a patient whos had Hypocalcaemia?
Prevents high calcium in urine and so helps prevent urinary tract stone formation
What is considered emergency Hypocalcaemia?
Ca2+ < 1.9mmol
What is the emergency treatment of emergency hypocalcaemia?
IV 10-20ml 10% Calcium gluconate in 200ml saline in 10mins and repeat when necessary
Check calcium 6hrly
What are the severe complications of acute hypocalcaemia?
Seizures
Laryngeal spasm
Prolonged QT syndrome (VT -> VF)
What is thr long term management of hypocalcaemia?
Calcium supplements
Vit D
Mg if needed
Monitor Ca2+, Phospphate and Mg every 3-6months
What is considered hyponatraemia?
Na+ < 133
What is the ranking of severity of hyponatraemia?
Mild 127 - 132
Moderate 121 -126
Severe <. 120
What are the 3 categories of causes of hyponatraemia?
Hypervolaemic
Euovolaemic
Hypovolaemic
What are some hypervolaemic causes of hyponatraemia?
Dilutional:
-CKD
-CHF
-Liver cirrhosis
-Nephrotic syndromes
What are some euovolaemic causes of hyponatraemia?
SIADH
Medications
Glucocorticoid deficiency
Severe hypothyroidism
What medications can cause hyponatraemia?
Thiazides diuretics
Loop diuretics
K+ sparring diuretics
ARBs (candesartan)
PPIs (omeprazole)
SSRIs
What are some hypovolaemic causes of hyponatraemia?
GI losses (N+V)
Burns
Sweating
Addisons disease
What is a common cause of hyponatraemia?
Pseudo
How is hypovolaemic hyponatraemia manage?
IV 0.9%NaCl
How is Euovolaemic hyponatraemia managed?
Rule out addisons, thyroid issues then SIADH
How do you investigate a hyponatraemia?
U+Es
Serum osmolality
Urine osmolality
Urine Na+
TFTs
Cortisol and ACTH levels
What is the management for hypervolaemic hyponatraemia?
Fluid restriction (<1.5L per day)
Diuretics
How is SIADH diagnosed?
Serum osmolality < 275mosm/kg
Urine osmolality > 100
Urine Na+ > 30mmol
Clinically euovolaemic
How is hyponatraemia caused by SIADH managed?
Fluid restriction < 1.5L per day
+
Demeclocycline
How does demeclocycline work in treating SIADH?
Causes Nephrogenic diabetes Insipidus to prevent kidney responding to the high levels of ADH
How quickly should sodium be corrected in a pateitn with mild moderate hyponatraemia?
0.5mmol/hr
What is the max correction of sodium in hyponatraemia that should be done in 24hrs and why?
8-10mmol
Risk of Osmotic demyelination syndrome
What is the severe complication of rapid correction of hyponatraemia?
Central pontine demyelinosis/ osmotic demyelination syndrome
How does hyponatraemia present?
Headaches
Nausea + vomiting
Fatigue
Confusion
Muscle cramps
Cerebral odema
Hyporeflexia
Respiratory arrest
What is the management of severe hyponatraemia?
IV 150ml 3% NaCl 20mins
Repeat 2. More times or until 5mmol/L increase in Na+
How does central pontine myelinosis or osmotic demyelination syndrome present?
Locked in syndrome
Dysphagia
What is considered severe/emergency hyponatraemia?
Na+ <120mmol
How does hypernatraemia present?
Thirst
Irritability
Muscle weakness
Confusion
Seizures
Coma
What is the management for hypernatraemia?
Hypotonic fluids like 0.45% NaCl aiming to reduce Na+ by 8-12mmol in 24hrs if severe
Mild. Moderate 8-10mmol correction in 24hrs
If patient is hypovolaemic and needs resus give normal. Saline until fluid replete
What hormones do the ovaries make?
Testosterone
Androstenedione
What sex hormones do the adrenal glands make?
DHEA
What are some causes of hyperandrogenism?
PCOS
Ovarian cancer
CAH
Cushings
Acromegaly
Adrenal adenoma
How does hyperandrogenism present?
Hirsutism
Acne
Signs of virilisation:
-frontal balding
-deep voice
-inc muscle mass
-clitoromegaly
What is primary amenorrhoea?
Failure to menstruate / menarche by 16
What is secondary amenorrhoea?
Had menses but ceased for 6months or more
What is oligomenorrhoea?
Less than 9 periods a year
What is primary hypogonadism?
Issue with th ovaries
What is secondary hypogonadism?
Issue with pituitary or hypothalamus which affects the ovaries
What hypothalamic issues can cause secondary hypogonadism?
Stress
Exercise
Weight loss
Kallmans syndrome
What pituitary issues can cause secondary hypogondism?
Autoimmune
Drugs
Cushings
Hyperprolactinaemia
Sheehans syndrome
What is Multiple Endocrine Neoplasia (MEN)?
Autosomal dominant mutations
What is MEN1 and what is its triad?
Autosomal dominatn mutation on chromosome 11
Pituitary adenoma
Parathyroid hyperplasia
Pancreatic tumour
What chromosome is affected with MEN2?
Autosomal dominatn mutation on chromosome 10
What investigations should be done for amenorrhoea?
Pregnancy test
LH
FSH
Prolactin
