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University of Aberdeenberdeen
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MainPoints
Main Points
Mechanism of Hypercalcaemia
Worth Treating Patient ?
After Patient is Discharged
-- Case Study Series
HNeil M Hamilton
$One V2.0
-- Copyright University
Aberdeen
-- 07/06/93
-- Please complete the registration form
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about
Case Study One. Developed by the Medical Faculty CAL Unit, University
of Aberdeen. Medical Content by Stuart Ralston, MD, FRCP. Design by Neil M Hamilton, BSc, PhD.
ReadTheNotes
A fifty year old man is admitted to Ward 47
with confusion, severe constipation, nausea and vomiting.
He is a smoker and shows signs of weight loss.
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Medi-CAL
nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnng Unit
University of Aberdeenberdeen
University of Aberdeenn
Hypercalcaemia Ieeee
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Bone Calcium Calculation
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Correct Answer:
Observed Calcium +
[[40 - Observed Albumin] x 0.02]
2.7 + ((40 - 20) x 0.02) =
2.7 + (20 x 0.02) =
2.7 + 0.4 = 3.1 mmol/lll3.1 mmol/l
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From the bone calcium test you found out that the calcium value was high. Calculate the Albumin corrected calcium.
Use the calculator if you wish.X ON THE RIGHT).
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The bone Ca value was 2.70 mmol/l
The albumin value was 20 g/l
Show the correct answer and calculationnnnnnnn
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No. This is the mediastinum.
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After Patient is Discharged
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"MonitorCalcium"
"GiveProphylaxis"
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No - some sort of follow up would be indicated.
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Yes - check weekly. Also, think
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A good suggestion, although life expectancy of these patients is short and not all will need prophylaxis. Monitoring calcium is also recommended.
You treat the patient with 0.9% saline 3 l/day for 2 days and give him 60mg i.v. pamidronate over 4h on day 1. The hypercalcaemia improves over the next few days and is normal after 5 days. He is well enough to discharge after 1 week.
What do you do now ??? (you may choose to do more than just one thing).
Give prophylaxis
Monitor calcium
Nothing
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Admission Details
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Mission
Your aim is to identify the correct treatment.
correct treatment.
(Use the mouse to click on the grey button of your choice)t, incorrect diagnosis or innefective treatment will reduce your credit points !
A fifty year old man is admitted to Ward 47 with confusion, severe constipation, nausea and vomiting. He is a smoker and shows signs of weight loss.
phadenopathy.
aclavicular lymphadenopathy.
signs of collapse of the L lung.
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Frusemide
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Bone Calcium Calculation
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answerbox
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Correct Answer:
Observed Calcium +
[[40 - Observed Albumin] x 0.02]
2.7 + ((40 - 20) x 0.02) =
2.7 + (20 x 0.02) =
2.7 + 0.4 = 3.1 mmol/lll3.1 mmol/l
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From the bone calcium test you found out that the calcium value was high. Calculate the Albumin corrected calcium.
Use the calculator if you wish.X ON THE RIGHT).
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HINT FOR CALCULATION
The bone Ca value was 2.70 mmol/l
The albumin value was 20 g/l
Show the correct answer and calculationnnnnnnn
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!H 6 6 %
Worth Treating Patient ?
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Do you think that it is worth treating the patient ?
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Admission Details
txclassname
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Mission
Your aim is to identify the correct treatment.
correct treatment.
(Use the mouse to click on the grey button of your choice)t, incorrect diagnosis or innefective treatment will reduce your credit points !
A fifty year old man is admitted to Ward 47 with confusion, severe constipation, nausea and vomiting. He is a smoker and shows signs of weight loss.
phadenopathy.
aclavicular lymphadenopathy.
signs of collapse of the L lung.
Browse Forwards.
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Cause of Hypercalcaemia
Xray1
Admission Details
results
Mechanism of Hypercalcaemia
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ProbableCauseText
What is the probable mechanism of the hypercalcaemia ??
EctopicPTH
"No, ectopic PTH
rarely a cause
cancer-associated hypercalcaemia."\
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"Reference"
"Hypercalcaemia
': Lancet 1987; ii; 1443-1445"
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No, ectopic PTH is rarely a cause of cancer-associated hypercalcaemia.
Yes. What factor do you think is being produced by the tumour ? Click OK and
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accept
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Some other tumour produced factor
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"Unlikely: massive amounts
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cause hypercalcaemia
patients
wrenal function, since the kidney can excrete
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Unlikely: massive amounts of bone mets are necessary to cause hypercalcaemia in patients with normal renal function, since the kidney can excrete the extra calcium.
Bone Metastases
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How to type in your answer
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Introduction
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History.
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University of Aberdeen, 1993
Portions of this application are the copyright of Asymetrix Corporationnn""""
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Medi-CAL
nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnng Unit
University of Aberdeenberdeen
University of Aberdeenn
Hypercalcaemia Ieeee
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!P P P &
Worth Treating Patient ?
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System
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Case Study One
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Medi-CAL
nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnng Unit
University of Aberdeenberdeen
University of Aberdeen
Hypercalcaemia Ieeee
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Browse Forwards./
LFT Results:
AAT 45 u/l
GGT 100 u/l
Bil 10
mol/l
AlkP 190u/l
Alb 20 g/l
Glob 30 g/l
Bone Calcium Result:
Ca 2.70 mmol/l
Plat 350 x 10 /ml
Alb 20 g/l
Glob 30 g/l
Haematology:
FBC: Hb 100g/l
WCC 15.0 x 10 /ml
Plat 350 x 10 /ml
lb 20 g/l
Glob 30 g/l
U+E Results:
Na 135 mmol/l
K 3.2 mol/l
Urea 4.8 mmol/l
Creat 110
mol/l
CO2 31O2 311
CT Scan, head: Normal CXR: L Lung Mass
CXR: L Lung Mass
L collapse
True3
"Yes. The calcium
high
the likely"&&\
"cause
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%hypercalcaemia
worse"&&\
"than you might think !"
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cause of his symptoms - and the hypercalcaemia is worse
than you might think !
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high
the likely"&&\
"cause
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%hypercalcaemia
"worse than you might think !"
buttonup
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cause of his symptoms - and the hypercalcaemia is
worse than you might think !
True1
"Yes. The LFT
abnormal. Is
the likely cause
his symptoms ?"\
x- although these results might indicate liver deposits."
"Correct. It
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Yes. The LFT is abnormal. Is this the likely cause of his symptoms ?
No it is not - although these results might indicate liver deposits.
Correct. It is not the likely cause of his symptoms. - although these results might indicate liver deposits.
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abnormal. Is
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True2
"Yes. There
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f"Yes"
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Correct. It is not the likely cause of his symptoms.
Is the calcium value high ?
Are the LFT values abnormal ?
e of anaemia ?
the calcium value high ?
ne: Ca 2.70 mmol/l
Is the calcium value high ?
Bone: Ca 2.70 mmol/l10 /ml ; Plat 350 x 10 /ml
Is the calcium value high ?
Bone: Ca 2.70 mmol/lium value high ?
Bone: Ca 2.70
Is there evidence of anaemia ?
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when you have selected the appropriate tests.e next page will reitterate these results so don't worry about copying them down...
"Certain types
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xdisplay"&&\
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"explain"
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explain
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MainBackground
Summary Page
LeavePage
"summarytable"
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LeavePage
summarytable
Confusion
Constipation
Nausea
Vomiting
Tumour
Hypercalcaemia
Constipation
stipation
Nausea
Vomiting
Nausea
stipation
Nausea
Vomiting
Vomiting
stipation
Nausea
Vomiting
The patient has a L lung tumour.
The tumour is responsible for the hypercalcaemia.
Hypercalcaemia can cause several symptoms and signs. In this case it is causing confusion, severe constipation,
Portions of this application are the copyright of Asymetrix Corporationnn""""
answerbox1
txclassname
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Initial Tests
LastPage
Browse Backwards.
You start the patient on oral clodronate and discharge him home. The GP checks his calcium weekly and it remains normal. He gradually deteriorates and dies of progressive carcinomatosis at home, 4 weeks after his admission.
Was the treatment worthwhile ?
Discuss with your colleagues
University of Aberdeen, 1993
Portions of this application are the copyright of Asymetrix Corporationnn""""
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t factor do you think is being produced by the tumour ? Click OK and
then type your answer in the box which appears.
accept
answer1
helpme
answer1
Some other tumour produced factor
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"Unlikely: massive amounts
bone mets are necessary
cause hypercalcaemia
patients
wrenal function, since the kidney can excrete
extra calcium."\
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Unlikely: massive amounts of bone mets are necessary to cause hypercalcaemia in patients with normal renal function, since the kidney can excrete the extra calcium.
Bone Metastases
helpme
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How to type in your answer
Type the name of the other factor (you can use an abbreviation if you want) in the yellow box.
If you make a mistake you can type over or delete the word.
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Introduction
Hypercalcaemia Responsibility
LastPage
Browse Backwards.
You start the patient on oral clodronate and discharge him home. The GP checks his calcium weekly and it remains normal. He gradually deteriorates and dies of progressive carcinomatosis at home, 4 weeks after his admission.
Was the treatment worthwhile ?
Discuss with your colleagues
University of Aberdeen, 1993
Portions of this application are the copyright of Asymetrix Corporationnn""""
txclassname
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Click on the unusual feature which you can see in the patient's X-ray..
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"Yes, the patient has some
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Yes, the patient has some sort of mass in the
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"explain"
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Introduction
ty CAL Menu Page 1
EnterPage
default
EnterPage
EnterPage
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txclassname
3DFrame Recessed
Click the browse button to startq
Browse Forwards.
University of Aberdeen, 1993
Portions of this application are the copyright of Asymetrix Corporationnn""""
Initial Tests
Browse Forwards.;
txclassname
3DFrame Recessed
You request the usual tests viz. U+E, Bone Calcium, LFT, TFT, CXR, Head Scan and FBC. Thankfully for the patient, you realize that a barium enema would not be appropriate in this case.
TestOptionText
The patient has been to X-ray and now the Chest X-ray is available for your perusal.
age when you have selected the appropriate tests.e next page will reitterate these results so don't worry about copying them down...
"Certain types
monitor may
xdisplay"&&\
"the CXR properly."
"explain"
"Xray"
buttonUp
buttonUp
Certain types of monitor may not display
the CXR properly.
explain
cxrbutton
Look at CXR
Browse Forwards.
Treatment
EnterPage
"Frusemide"
"Fluids"
"Mithramycin"
"Calcitonin"
"Bisphosphonate"
default
LeavePage
EnterPage
LeavePage
EnterPage
Frusemide
Fluids
Mithramycin
Calcitonin
Bisphosphonate
default
LeavePage
Frusemide
Fluids
Mithramycin
Calcitonin
Bisphosphonate
Frusemide
Frusemide: No.This would just make him dehydrated and make things worse. Try some of the other options.ions.
Fluids
Fluids: Yes. Intravenous fluids will help calcium excretion. Use saline not dextrose though, since a sodium diuresis promotes a calcium diuresis by reducing calcium reabsorption in the proximal renal tubule. Try some of the other options.ions..
Mithramycin
Mithramycin: No. Mithramycin is too toxic and has been superseded. Try some of the other options..ons.
Calcitonin
Calcitonin: Possibly. This is an effective hypercalcaemic drug, however the reaction of calcitonin is relatively short. Calcitonin is useful for the rapid control of more severe hypercalcaemia since it works quickly. Try some of the other options........e above options.
Bisphosphonate
Bisphosphonate: Yes. Bisphosphonates are potent inhibitors of bone resorption and with their long duration of action are the treatment of choice ! Try some of the other options..ons.ht be worth considering ?
Which treatment do you administer?
Mithramycin
Fluidside
Frusemide
"Frusemide"
"Fluids"
"Mithramycin"
"Calcitonin"
"Bisphosphonate"
buttonup
buttonup
Frusemide
Fluids
Mithramycin
Calcitonin
Bisphosphonate
Bisphosphonate
Calcitonin
"Frusemide"
"Fluids"
"Mithramycin"
"Calcitonin"
"Bisphosphonate"
FALSE
buttonup
buttonup
Frusemide
Fluids
Mithramycin
Calcitonin
Bisphosphonate
"Frusemide"
"Fluids"
"Mithramycin"
"Calcitonin"
"Bisphosphonate"
FALSE
buttonup
buttonup
Frusemide
Fluids
Mithramycin
Calcitonin
Bisphosphonate
txclassname
3DFrame Recessed
answerbox1
txclassname
3DFrame
"Frusemide"
"Fluids"
"Mithramycin"
"Calcitonin"
"Bisphosphonate"
buttonup
buttonup
Frusemide
Fluids
Mithramycin
Calcitonin
Bisphosphonate
"Frusemide"
"Fluids"
"Mithramycin"
"Calcitonin"
"Bisphosphonate"
buttonup
buttonup
Frusemide
Fluids
Mithramycin
Calcitonin
Bisphosphonate
Browse Forwards.
Hypercalcaemia Responsibility
EnterPage
default
LeavePage
EnterPage
LeavePage
EnterPage
false
0,100,0
false
0,100,0
default
LeavePage
false
0,100,0
false
0,100,0
Browse Forwards.=
"Yes. The hypercalcaemia could explain
the presenting symptoms."\
buttonup
buttonup
120,50,100
Yes. The hypercalcaemia could explain all of the presenting symptoms.
False
"Wrong. The hypercalcaemia could explain
the presenting symptoms."\
buttonup
buttonup
0,50,100
Wrong. The hypercalcaemia could explain all of the presenting symptoms.
TreatmentText
Do you think that the hypercalcaemia could explain all the presenting symptoms ??
txclassname
3DFrame Recessed
answerbox1
txclassname
3DFrame
Browse Forwards.
Cause of Hypercalcaemia
EnterPage
"answer1"
B"accept"
"help"
B"helpme"
B"TheTumor"
B"Hyperparathyroidism"
B"Theconfusion"
B"Theanaemia"
default
LeavePage
EnterPage
LeavePage
EnterPage
answer1
accept
helpme
TheTumor
Hyperparathyroidism
Theconfusion
Theanaemia
TheTumor
0,100,0
Hyperparathyroidism
0,100,0
Theconfusion
0,100,0
Theanaemia
0,100,0
default
LeavePage
Hyperparathyroidism
Theconfusion
Theanaemia
TheTumor
0,100,0
Hyperparathyroidism
0,100,0
Theconfusion
0,100,0
Theanaemia
0,100,0
answer1
accept
helpme
answer1
Browse Forwards.
answer1
helpme
"help"
buttonUp
buttonUp
pthtext
How to type in your answer
Type the test name which would confirm the diagnosis of hyperparathyroidism (you can use an abbreviation if you want).
If you make a mistake you can type over or delete the word.
When you are satisfied with your answer click on the 'Accept' button. utton. he 'Accept Answer' button.
"help"
"answer1"
buttonUp
buttonUp
answer1
Accept
Accept
HypercalcText
What is the cause of the hypercalcaemia ?
Hyperparathyroidism
"Unlikely, but
also a common cause"&&\
hypercalcaemia. What single test would confirm"&&\
"a diagnosis
hyperparathyroidism ? Click OK
Ftype your answer"&&\
the box which appears."
"answer1"
B"accept"
B"helpme"
buttonup
buttonup
60,50,100
Unlikely, but this is also a common cause
of hypercalcaemia. What single test would confirm
a diagnosis of hyperparathyroidism ? Click OK and then type your answer
in the box which appears.
answer1
accept
helpme
answer1
Hyperparathyroidism
Theanaemia
"Wrong."
buttonup
buttonup
0,50,100
Wrong.
The Anaemia
TheConfusion
"No. This
the result,
cause
hypercalcaemia."
buttonup
buttonup
0,50,100
No. This is the result, not the cause of hypercalcaemia.
The Confusion
TheTumor
"This
almost certainly the cause."&&\
"Hypercalcaemia
a common complication
cancer,"&&\
"especially lung
. Look
^Hyperparathyroidism"&&\
"option
details
another
hypercalcaemia."
buttonup
buttonup
120,50,100
This is almost certainly the cause.
Hypercalcaemia is a common complication of cancer,
especially lung cancer. Look at the Hyperparathyroidism
option for details of another cause of hypercalcaemia.
The Tumour
txclassname
3DFrame Recessed
answerbox1
txclassname
3DFrame
Browse Forwards.
Main Points
MainPoints
Hypercalcaemia is a common problem both in hospital medicine and in general practice. It is not a disease in itself, but metabolic complication of disease. Many underlying diseases can be complicated by hypercalcaemia and because of this most doctors will encounter hypercalcaemic as a diagnostic and theraputic problem.
MAIN POINTS
(1) Hypercalcaemia is not a disease in itself but a metabolic complication of one of many underlying disease processes.
(2) Hypercalcaemia is due to failure of the normal homeostatic mechanisms responsible for regulation of plasma calcium. These involve the calciotropic hormones PTH and 1,25 DHCC and their sites of action in bone intestine and kidney.
(3) Mild hypercalcaemia may be asymptomatic but symptoms become progressively more common as hypercalcaemia worsens.
(4) The symptoms of hypercalcaemia are non-specific and often overlooked or mistaken for those of other diseases.
(5) Severe hypercalcaemia is a MEDICAL EMERGENCY; it can cause irreversible organ damage and may be fatal!
(6) The two most common causes of hypercalcaemia are cancer and primary hyperparathyroidism.
(7) The best method of treating hypercalcaemia is to define and treat the underlying cause.
(8) Medical antihypercalcaemia therapy may be required where the primary cause cannot be treated (usually in cancer patients)
(9) Medical antihypercalcaemic therapy consists of intravenous saline (to increase urinary calcium excretion) and bisphosphonates (to inhibit bone resorption) bone resorption)))))))))))))))))ause cannot be treated (usually in cancer patients)
(9) Medical antihypercalcaemic therapy consists of intravenous saline (to increase urinary calcium excretion) and bisphosphonates (to inhibit bone resorption)))))))))))))))))))))common problem both in hospital medicine and in general practice. It is
not a
disease in itself, but metabolic complication of disease. Many underlying diseases can be
complicated by hypercalcaemia and because of this most doctors will encounter
hypercalcaemic as a
diagnostic and theraputic problem. This programme gives details on the normal control of
calcium
homeostasis, differential diagnosis and management of hypercalcaemia.
ESTIMATED STUDY TIME
1-2 Hours
HOW TO USE THIS MATERIAL
You can complete this program in two ways:
(1) By working through the document on computer (Mac and PC versions available)
(2) By working through the written document.
Whatevere you choose, test your knowledge at the end by working through the
hypercalcaemia quiz
(on disk, available from library issue desk).
LEARNING POINTS
(1) Hypercalcaemia is not a disease in itself but a metabolic complication of one of many
underlying
disease processes.
(2) Hypercalcaemia is due to failure of the normal homeostatic mechanisms responsible for
regulation
of plasma calcium. These involve the calciotropic hormones PTH and 1,25 DHCC and their
sites of
action in bone intestine and kidney.
(3) Mild hypercalcaemia may be asymptomatic but symptoms become progressively more
common as
hypercalcaemia worsens.
(4) The symptoms of hypercalcaemia are non-specific and often overlooked or mistaken for
those of
other diseases.
(4) Severe hypercalcaemia is a MEDICAL EMERGENCY; it can cause irreversible organ
damage and
may be fatal!
(5) The two most common causes of hypercalcaemia are cancer and primary
hyperparathyroidism.
(6) The best method of treating hypercalcaemia is to define and treat the underlying cause.
(8) Medical antihypercalcaemia therapy may be required where the primary cause cannot be
treated
(usually in cancer patients)
(9) Medical antihypercalcaemic therapy consists of intravenous saline (to increase urinary
calcium
excretion) and bisphosphonates (to inhibit bone resorption).
underlying cause.
(8) Medical antihypercalcaemia therapy may be required where the primary cause cannot be
treated
(usually in cancer patients)
(9) Medical antihypercalcaemic therapy consists of intravenous saline (to increase urinary
calcium
excretion) and bisphosphonates (to inhibit bone resorption).
tes (to inhibit bone resorption).
nhibit bone resorption).
apy consists of intravenous saline (to increase urinary
calcium
excretion) and bisphosphonates (to inhibit bone resorption).
HYPERCALCAEMIA SELF LEARNING MODULE
This text is taken directly from the handout
ASSESSMENT AND MANAGEMENT OF HYPERCALCAEMIAA ASSESSMENT AND MANAGEMENT OF HYPERCALCAEMIAAAAAAAAA MANAGEMENT OF HYPERCALCAEMIA{
txclassname
3DFrame Recessed
answerbox1
txclassname
3DFrame
Go to last visited page.
Cause of Hypercalcaemia
EnterPage
"answer1"
B"accept"
"help"
B"helpme"
B"TheTumor"
B"Hyperparathyroidism"
B"Theconfusion"
B"Theanaemia"
default
LeavePage
EnterPage
LeavePage
EnterPage
answer1
accept
helpme
TheTumor
Hyperparathyroidism
Theconfusion
Theanaemia
TheTumor
0,100,0
Hyperparathyroidism
0,100,0
Theconfusion
0,100,0
Theanaemia
0,100,0
default
LeavePage
Hyperparathyroidism
Theconfusion
Theanaemia
TheTumor
0,100,0
Hyperparathyroidism
0,100,0
Theconfusion
0,100,0
Theanaemia
0,100,0
answer1
accept
helpme
answer1
Browse Forwards.
answer1
helpme
"help"
buttonUp
buttonUp
pthtext
How to type in your answer
Type the test name which would confirm the diagnosis of hyperparathyroidism (you can use an abbreviation if you want).
If you make a mistake you can type over or delete the word.
When you are satisfied with your answer click on the 'Accept' button. utton. he 'Accept Answer' button.
"help"
"answer1"
buttonUp
buttonUp
answer1
Accept
Accept
HypercalcText
What is the cause of the hypercalcaemia ?
Hyperparathyroidism
"Unlikely, but
also a common cause"&&\
hypercalcaemia. What single test would confirm"&&\
"a diagnosis
hyperparathyroidism ? Click OK
Ftype your answer"&&\
the box which appears."
"answer1"
B"accept"
B"helpme"
buttonup
buttonup
60,50,100
Unlikely, but this is also a common cause
of hypercalcaemia. What single test would confirm
a diagnosis of hyperparathyroidism ? Click OK and then type your answer
in the box which appears.
answer1
accept
helpme
answer1
Hyperparathyroidism
Theanaemia
"Wrong."
buttonup
buttonup
0,50,100
Wrong.
The Anaemia
TheConfusion
"No. This
the result,
cause
hypercalcaemia."
buttonup
buttonup
0,50,100
No. This is the result, not the cause of hypercalcaemia.
The Confusion
TheTumor
"This
almost certainly the cause."&&\
"Hypercalcaemia
a common complication
cancer,"&&\
"especially lung
. Look
^Hyperparathyroidism"&&\
"option
details
another
hypercalcaemia."
buttonup
buttonup
120,50,100
This is almost certainly the cause.
Hypercalcaemia is a common complication of cancer,
especially lung cancer. Look at the Hyperparathyroidism
option for details of another cause of hypercalcaemia.
(.txt)