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Asymetrix ToolBook File | 1993-12-14 | 153KB | 2,838 lines

--This handler tests alphabetic data only "answer2" --localize the "Type your kbox. Do xuse numbers,"&&\ "hyphens tabs."\ f"OK" "Cancel" syssuspendmessages ) >= 65 ) <= 90 ) >= 97 ) <= 122 "&&\ f"OK" "PTHrP" "Parathyroid Hormone Releasing Peptide, ( correct. a hormone which"&&\ "mimics effects n on bone kidney commonest"&&\ "reason hypercalcaemia malignancy." B"pthrp" "help" B"BoneMetastases" B"EctopicPTH" B"OtherFactor" "related"\ "peptide" "releasing"\ PTH on "Wrong. buttonUp buttonUp answer2 Type your answer in the yellow box. Do not use numbers, hyphens or tabs. Cancel Cancel Type your answer in the yellow box. Do not use numbers, hyphens or tabs. Cancel Cancel answer2 PTHrP Parathyroid Hormone Releasing Peptide, (PTHrP), is correct. This is a hormone which mimics the effects of PTH on bone and kidney and is the commonest reason for hypercalcaemia in malignancy. answer2 answer2 pthrp BoneMetastases EctopicPTH OtherFactor answer2 Parathyroid answer2 Hormone answer2 related answer2 peptide Parathyroid Hormone Releasing Peptide, (PTHrP), is correct. This is a hormone which mimics the effects of PTH on bone and kidney and is the commonest reason for hypercalcaemia in malignancy. answer2 answer2 pthrp BoneMetastases EctopicPTH OtherFactor answer2 Parathyroid answer2 Hormone answer2 releasing answer2 peptide Parathyroid Hormone Releasing Peptide, (PTHrP), is correct. This is a hormone which mimics the effects of PTH on bone and kidney and is the commonest reason for hypercalcaemia in malignancy. answer2 answer2 pthrp BoneMetastases EctopicPTH OtherFactor Wrong. Parathyroid Hormone Releasing Peptide, (PTHrP), is correct. This is a hormone which mimics the effects of PTH on bone and kidney and is the commonest reason for hypercalcaemia in malignancy. answer2 pthrp BoneMetastases EctopicPTH OtherFactor Hyperparathyroidism Test Cause of Back Pain Likely Diagnosis after Testing ButtonDown Jvisited "explain" ButtonDown buttonUp ButtonDown Go to last visited page. explain buttonUp explain txClassName button defStroke 0,0,0 ClassName button "Look up the Help Contents." "explain" contents buttonDown buttonUp buttonDown Look up the Help Contents. explain buttonUp ycontents explain txClassName button ButtonDown "History." "explain" ButtonDown buttonUp ButtonDown History. explain buttonUp Yhistory explain defStroke 0,0,0 txClassName button txButton txClassName button Medi-CAL nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnng Unit University of Aberdeenberdeen University of Aberdeen Hypercalcaemia IIeee ButtonDown "Exit the "explain" "Quit Case Study Two ?"\ f"Yes" SysSuspendMessages ButtonDown buttonUp ButtonDown Exit the application. explain buttonUp Quit Case Study Two ? explain txClassName button defStroke 0,0,0 ButtonDown "explain" ButtonDown buttonUp ButtonDown Go to the first page. explain buttonUp explain txclassname 3DFrame Recessed explain ButtonDown "Return CAL Menu." "explain" X"user" bringWindowToTop( toolbook M"casemenu.tbk" bringwindowtotop( b doesn't even un-iconize 47,119" default ButtonDown buttonUp ButtonDown Return to this CAL Menu. explain buttonUp explain bringWindowToTop sysWindowHandle casemenu.tbk bringwindowtotop set position of mainWindow to 47,119 casemenu.tbk casemenu.tbk default toolbook defStroke 0,0,0 txClassName button Previous txClassName button txClassName button defStroke 0,0,0 0,0,0 button Previous ButtonDown "Browse Backwards." "explain" ButtonDown buttonUp ButtonDown Browse Backwards. explain buttonUp explain defStroke 0,0,0 ButtonDown "Browse Forwards." "explain" ButtonDown buttonUp ButtonDown Browse Forwards. explain buttonUp explain defStroke 0,0,0 txClassName Introduction EnterPage default EnterPage EnterPage default txclassname 3DFrame Recessed Click the browse button to startK Browse Forwards. To refer or not to refer Outcome after Treatment Summary after Treatment -- Case Study Series HDr Neil M Hamilton 'Two V2.0a -- Copyright University Aberdeen -- 07/06/93 -- Please complete the registration form notify us bugs innacuracies. Mfeel free e, revise reuse ]scripts -- You may x, however, entire a substantial -- part redistribution %your own product. -- Portions are copyright Asymetrix Corporation- EnterBook --general initialization Reader --Preparing c"Edit" c"Text" c"File" c"Help" "SelectPage" c"Admission Notes" c"Tools" notes" e"Calculator" e"Notepad" e"Contents" e"Windows Tutorial" e"About" --Declaring a widgets font ("dva-4000.tbk") ("tbkmm.sbk") --Removing re-sizing boxes linkDLL "user.exe" INT ShowWindow(WORD, FindWindow(STRING, PostMessage( 8LONG) SendMessage( SetFocus( DWORD GetWindowLong( SetWindowLong( 6 GetMenu( H GetSubMenu( ` GetMenuITemID( DeleteMenu( DrawMenuBar( POPUPNUM 2147483648 MINIMIZEBOXNUM 131072 MAXIMIZEBOXNUM 65536 SYSMENUNUM 524288 CAPTIONNUM 12582912 THICKFRAMENUM 262144 2147483648 ,-16) ,-16, --Customised Handlers calculator bringWindowToTop( toolbook M"casecalc. bringwindowtotop( a doesn't even un-iconize 47,119" default notepad INT hWnd - (Untitled)") "c:\windows\ P, 1) contents 0,"Medical Faculty CAL "aberdeen.hlp" WindowsTutorial 0,"Microsoft "wintutor. about Two. Developed Unit, HStuart Ralston, MD, FRCP. Design U , BSc, PhD." ReadTheNotes "A seventy two year old woman was sent up D clinic"&&\ .pain chest pains. Her GP discovered that she L"&&\ "hypertensive (180/100) some five years previously has"&&\ "treated her fbendrofluazide 2.5mg/day. referral letter"&&\ cdetails blood tests performed --Cursor Control --Alphabetic Input data accept buttons alphacheck "answer1" "Type kbox. Do numbers, "&&\ "hyphens tabs." ) >= 65 ) <= 90 ) >= 97 ) <= 122 alphabetic --The LeaveBook handler lculator WindowsTutorial about EnterBook ReadTheNotes notepad enterPage leavePage contents alphacheck calculator LeaveBook EnterBook sizetopage SelectPage Admission Notes Tools Read the notes Admission Notes Calculator Tools Notepad Tools Contents Windows Tutorial About tbkmm.sbk user.exe ShowWindow FindWindow PostMessage SendMessage SetFocus GetWindowLong SetWindowLong GetMenu GetSubMenu GetMenuITemID DeleteMenu DrawMenuBar GetWindowLong SetWindowLong SYSMENUNUM MAXIMIZEBOXNUM MINIMIZEBOXNUM POPUPNUM calculator bringWindowToTop sysWindowHandle casecalc.tbk bringwindowtotop set position of mainWindow to 47,119 casecalc.tbk casecalc.tbk default toolbook notepad FindWindow ShowWindow Notepad - (Untitled) FindWindow c:\windows\notepad.exe ShowWindow default contents FindWindow ShowWindow Medical Faculty CAL Help FindWindow aberdeen.hlp ShowWindow default WindowsTutorial FindWindow ShowWindow Microsoft Tutorial FindWindow wintutor.exe ShowWindow default about Case Study Two. 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 seventy two year old woman was sent up to the clinic with back pain and chest pains. Her GP discovered that she was hypertensive (180/100) some five years previously and has treated her with bendrofluazide 2.5mg/day. The referral letter contains details of blood tests performed by the GP. enterPage default leavePage alphacheck answer1 Type your answer in the yellow box. Do not use numbers, hyphens or tabs. answer1 Type your answer in the yellow box. Do not use numbers, hyphens or tabs. answer1 LeaveBook Results MainBackground Handle EnterBackground LeaveBackground ackground EnterBackground LeaveBackground EnterBackground LeaveBackground Medi-CAL nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnng Unit University of Aberdeenberdeen University of Aberdeen Hypercalcaemia IIeee txclassname 3DFrame Recessed explain ButtonDown "Browse Forwards." "explain" ButtonDown buttonUp ButtonDown Browse Forwards. explain buttonUp explain defStroke 0,0,0 txClassName button Previous ButtonDown "Browse Backwards." "explain" ButtonDown buttonUp ButtonDown Browse Backwards. explain buttonUp explain defStroke 0,0,0 txClassName button ButtonDown "Return CAL Menu." "explain" X"user" bringWindowToTop( toolbook M"casemenu.tbk" bringwindowtotop( b doesn't even un-iconize 47,119" default ButtonDown buttonUp ButtonDown Return to this CAL Menu. explain buttonUp explain bringWindowToTop sysWindowHandle casemenu.tbk bringwindowtotop set position of mainWindow to 47,119 casemenu.tbk casemenu.tbk default toolbook defStroke 0,0,0 txClassName button Previous ButtonDown "Exit the "explain" "Quit Case Study Two ?"\ f"Yes" SysSuspendMessages ButtonDown buttonUp ButtonDown Exit the application. explain buttonUp Quit Case Study Two ? explain txClassName button defStroke 0,0,0 ButtonDown "explain" ButtonDown buttonUp ButtonDown Go to the first page. explain buttonUp explain txClassName button defStroke 0,0,0 ButtonDown "History." "explain" ButtonDown buttonUp ButtonDown History. explain buttonUp Yhistory explain defStroke 0,0,0 txClassName button "Look up the Help Contents." "explain" contents buttonDown buttonUp buttonDown Look up the Help Contents. explain buttonUp ycontents explain ButtonDown Jvisited "explain" ButtonDown buttonUp ButtonDown Go to last visited page. explain buttonUp explain txClassName button defStroke 0,0,0 "Look up the Help Contents." "explain" contents ButtonDown buttonUp ButtonDown Look up the Help Contents. explain buttonUp ycontents explain txClassName button CLASSname txButton Medi-CAL nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnng Unit University of Aberdeenberdeen University of Aberdeenn explain Hypercalcaemia Ieeee ButtonDown "Return CAL Menu." "explain" X"user" bringWindowToTop( toolbook M"casemenu.tbk" bringwindowtotop( b doesn't even un-iconize 47,119" default ButtonDown buttonUp ButtonDown Return to this CAL Menu. explain buttonUp explain bringWindowToTop sysWindowHandle casemenu.tbk bringwindowtotop set position of mainWindow to 47,119 casemenu.tbk casemenu.tbk default toolbook txClassName button defStroke 0,0,0 txclassname 3DFrame Recessed Previous defStroke 0,0,0 txClassName button ButtonDown "Exit the "explain" "Remember - You should have a hand-out"&&\ "on hypercalcaemia which details reference material."&&\ "Read those references more information."&&\ "Quit Case Study Two ?"\ f"Yes" SysSuspendMessages ButtonDown buttonUp ButtonDown Exit the application. explain buttonUp Remember - You should have a hand-out on hypercalcaemia which details reference material. Read those references for more information. Quit Case Study Two ? explain ButtonDown Jvisited "explain" ButtonDown buttonUp ButtonDown Go to last visited page. explain buttonUp explain defStroke 0,0,0 txClassName button ButtonDown "explain" ButtonDown buttonUp ButtonDown Go to the first page. explain buttonUp explain defStroke 0,0,0 txClassName button ButtonDown "History." "explain" ButtonDown buttonUp ButtonDown History. explain buttonUp Yhistory explain txClassName button defStroke 0,0,0 Summary after Treatment Browse Backwards. University of Aberdeen, 1993 Portions of this application are the copyright of Asymetrix Corporationnn"""" txclassname 3DFrame Recessed answerbox1 txclassname 3DFrame MainPoints "Main Points" buttonUp buttonUp Main Points This is a typical case of PHPT. The disease is commonest in post-menopausal women and this group seem to run an increased risk of osteoporosis and the presence of osteoporosis is a positive indication for surgical treatment. Bone density generally increases (often quite substantially) after successful surgery. The reversal of hypertension after PTX is also well documented. Go to the first page. To refer or not to refer EnterPage "one" "two" "three" "four" "five" default LeavePage EnterPage LeavePage EnterPage three default LeavePage three Browse Forwards. Nothing No - some sort of follow up would be indicated. MonitorCalcium Yes - check weekly. Also, think about giving prophylaxis. GiveProphylaxis A good suggestion, although life expectancy of these patients is short and not all will need prophylaxis. Monitoring calcium is also recommended. TestOptionText The diagnosis looks like PHPT. Osteoporosis is a well recognised complication of PHPT in postmenopausal women (see reference 16 in main document). What would you do now? Give bisphosphonates Observe "one" "two" "three" "four" "five" buttonUp buttonUp three Parathyroid scan de levels to see if they are raised Refer for parathyroidectomy Limit dietary calcium intake Parathyroid scan: No, localising investigations are not indicated in PHPT, except in the very rare cases where a neck exploration has failed to uncover a PT adenoma. Parathyroids can occasionally be 'ectopic' and lie in the mediastinum............................. three Observe: No. She has complications (osteoporosis and hypertension) which may respond to parathyroidectomy........ Limit dietary calcium intake: No. This actually would make her osteoporosis worse and would make little impact on the hypercalcaemia..............................ractures. Bisphosphonates: No. These can be helpful in patients with severe hypercalcaemia in the pre-operative phase. They do not work well in mild PHPT since the hypercalcaemia is often largely due to increased renal tubular calcium reabsorption. Parathyroidectomy: Yes. The treatment of choice for PHPT. txclassname 3DFrame Recessed answerbox1 txclassname 3DFrame "one" "two" "three" "four" "five" buttonUp buttonUp three "one" "two" "three" "four" "five" buttonUp buttonUp three "one" "two" "three" "four" "five" buttonUp buttonUp three "one" "two" "three" "four" "five" buttonUp buttonUp three Browse Forwards. uttonUp three "one" "two" "three" "four" "five" buttonUp buttonUp three Treatment The Patient Presents LastPage Relevant Drug Intake Medi-CAL nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnng Unit University of Aberdeenberdeen University of Aberdeenn Hypercalcaemia IIeee txclassname 3DFrame Recessed explain Previous ButtonDown "Browse Backwards." "explain" ButtonDown buttonUp ButtonDown Browse Backwards. explain buttonUp explain v defStroke 0,0,0 txClassName button ButtonDown "Return CAL Menu." "explain" X"user" bringWindowToTop( toolbook M"casemenu.tbk" bringwindowtotop( b doesn't even un-iconize 47,119" default ButtonDown buttonUp ButtonDown Return to this CAL Menu. explain buttonUp explain bringWindowToTop sysWindowHandle casemenu.tbk bringwindowtotop set position of mainWindow to 47,119 casemenu.tbk casemenu.tbk default toolbook defStroke 0,0,0 txClassName button Previous ButtonDown "Exit the "explain" "Quit Case Study Two ?"\ f"Yes" SysSuspendMessages ButtonDown buttonUp ButtonDown Exit the application. explain buttonUp Quit Case Study Two ? explain txClassName button defStroke 0,0,0 ButtonDown "explain" ButtonDown buttonUp ButtonDown Go to the first page. explain buttonUp explain txClassName button defStroke 0,0,0 ButtonDown "History." "explain" ButtonDown buttonUp ButtonDown History. explain buttonUp Yhistory explain defStroke 0,0,0 txClassName button "Look up the Help Contents." "explain" contents buttonDown buttonUp buttonDown Look up the Help Contents. explain buttonUp ycontents explain ButtonDown Jvisited "explain" ButtonDown buttonUp ButtonDown Go to last visited page. explain buttonUp explain txClassName button defStroke 0,0,0 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). txclassname 3DFrame 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 Browse Backwards. 3DFrame Recessed answerbox1 txclassname Browse Backwards. Summary after Treatment Browse Backwards. University of Aberdeen, 1993 Portions of this application are the copyright of Asymetrix Corporationnn"""" txclassname 3DFrame Recessed answerbox1 txclassname 3DFrame MainPoints "Main Points" buttonUp buttonUp Main Points This is a typical case of PHPT. The disease is commonest in post-menopausal women and this group seem to run an increased risk of osteoporosis and the presence of osteoporosis is a positive indication for surgical treatment. Bone density generally increases (often quite substantially) after successful surgery. The reversal of hypertension after PTX is also well documented. EnterPage "explain" default LeavePage EnterPage LeavePage EnterPage explain default LeavePage Outcome after Treatment The patient undergoes parathyroidectomy and a single adenoma is removed from the R inferior position. One year later she is feeling well. There have been no more episodes of back pain and spinal bone density measurements have shown an increase of 15%!! Her BP is now normal without therapy. Well done ! Please move on one page for a summary.... answerbox1 txclassname 3DFrame txclassname 3DFrame Recessed EnterPage "explain" default LeavePage EnterPage LeavePage EnterPage explain default LeavePage Browse Backwards. txclassname Main Points Possible Thiazide Involvement First Moves EnterPage three default LeavePage EnterPage LeavePage EnterPage default three LeavePage three Browse Forwards. TestOptionText What would you do now ? to perform? Choose only relevant tests.. Look at the values and decide whether they are normal or abnormal. The next page will reitterate these results so don't worry about copying them down... Take a detailed drug history Order a whole body MRI scan with contrast enhancementttt Tell her that her doctor was worrying about nothing and she has probably just pulled a muscle in her back "one" "two" "three" buttonUp buttonUp three Pulled Muscle: Find a good lawyer - you'll need one for the GMC hearing and the litigation. Drug History: Yes. You would of course do this anyway but it is especially important in hypercalcaemia. three Whole Body MRI Scan: There's no such thing. B txclassname 3DFrame Recessed "one" "two" "three" buttonUp buttonUp three "one" "two" "three" buttonUp buttonUp three answerbox1 txclassname 3DFrame Browse Backwards. "No." buttonup buttonup 0,50,100 Calcium Antagonists txclassname 3DFrame Recessed answerbox1 txclassname 3DFrame Considering Diagnoses Outcome after Treatment The patient undergoes parathyroidectomy and a single adenoma is removed from the R inferior position. One year later she is feeling well. There have been no more episodes of back pain and spinal bone density measurements have shown an increase of 15%!! Her BP is now normal without therapy. Well done ! Please move on one page for a summary.... answerbox1 txclassname 3DFrame txclassname 3DFrame Recessed Browse Forwards. The Patient Presents Browse Backwards. EnterPage default EnterPage EnterPage default A seventy two year old woman is sent up to the clinic with back pain and chest pains. Her GP discovered that she was hypertensive (180/100) some five years previously and has treated her with bendrofluazide 2.5mg/day. The referral letter contains details of blood tests performed by the GP. Your aim is to identify the correct treatment. txclassname 3DFrame Recessed EnterPage "explain" default LeavePage EnterPage LeavePage EnterPage explain default LeavePage --This handler tests alphabetic data only "answer1" --localize the "Type your kbox. Do xuse numbers, "&&\ "hyphens tabs."\ f"OK" "Cancel" syssuspendmessages ) >= 65 ) <= 90 ) >= 97 ) <= 122 f"OK" "PTH" "Yes. Parathyroid Hormone, ( correct. The 5 would be raised." B"pth" "help" B"TheTumor" B"Hyperparathyroidism" B"Theconfusion" B"Theanaemia" PTH), "Sorry. buttonUp buttonUp answer1 Type your answer in the yellow box. Do not use numbers, hyphens or tabs. Cancel Cancel Type your answer in the yellow box. Do not use numbers, hyphens or tabs. Cancel Cancel answer1 Yes. Parathyroid Hormone, (PTH), is correct. The PTH would be raised. answer1 answer1 TheTumor Hyperparathyroidism Theconfusion Theanaemia answer1 Parathyroid Hormone Yes. Parathyroid Hormone, (PTH), is correct. The PTH would be raised. answer1 answer1 TheTumor Hyperparathyroidism Theconfusion Theanaemia Sorry. Parathyroid Hormone, (PTH), is correct. The PTH would be raised. answer1 TheTumor Hyperparathyroidism Theconfusion Theanaemia Thiazide Experiment Results System MS Sans Serif MS Sans Serif se Study One MS Sans Serif Case Study Two ********** MS Sans Serif Courier New MS Sans Serif MS Sans Serif TBKWidgets gD|D|} KWidgets \D|D| TBKWidgets MS Sans Serif windowtotop( doesn't even un-iconize SizeToPage" app isn't running, so we'll "casehelp.tbk" LeaveBook terBook HelpMainMenu EnterBook LeaveBook EnterBook sizeToPage Help Me Help Main Menu Help Me HelpMainMenu bringWindowToTop sysWindowHandle bringwindowtotop send SizeToPage casehelp.tbk fAppName toolbook LeaveBook System all Fonts all Fonts c"File" c"Help" Me" Main Menu" 2 Me" HelpMainMenu X"user" --bringWindowToTop a Windows function that puts the + whose passed front %other windows. toolbook MfAppName bringwindowtotop( doesn't even un-iconize SizeToPage" app isn't running, so we'll "casehelp.tbk" LeaveBook terBook HelpMainMenu EnterBook LeaveBook EnterBook sizetopage Help Me Help Main Menu Help Me HelpMainMenu bringWindowToTop sysWindowHandle bringwindowtotop send SizeToPage casehelp.tbk fAppName toolbook LeaveBook System Sans Serif Script Script mes New Roman System Small Fonts TBKWidgets MS Sans Serif app isn't running, so we'll "casehelp.tbk" LeaveBook terBook HelpMainMenu EnterBook LeaveBook EnterBook sizetopage Help Me Help Main Menu Help Me HelpMainMenu bringWindowToTop sysWindowHandle bringwindowtotop send SizeToPage casehelp.tbk fAppName toolbook LeaveBook First Moves Introduction Introduction EnterPage default EnterPage EnterPage default Click the browse button marked & to starttrt txclassname 3DFrame Recessed Browse Backwards. University of Aberdeen, 1993 Portions of this application are the copyright of Asymetrix Corporationnn"""" Browse Backwards. txclassname 3DFrame Recessed Click the Help button marked ? or choose Help from the menubar at the top of the page if you are stuck. Glossary of Complications. EnterPage "explain" default LeavePage EnterPage LeavePage EnterPage explain default LeavePage three "one" "two" "three" buttonUp buttonUp three answerbox1 txclassname 3DFrame Browse Forwards. Hyperparathyroidism Test EnterPage "help" "answer1" default LeavePage EnterPage LeavePage EnterPage answer1 answer1 default LeavePage answer1 Browse Forwards. You have now eliminated thiazide induced hypercalcaemia as a diagnosis. That leaves you with hyperparathyroidism as a possibility. If you could do a single test to make the diagnosis, what would it be? answer1 Accept "help" buttonUp buttonUp pthrp How to type in your answer Type the name of the single test, in the yellow box (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. tton. nswer' button. "help" "answer1" buttonUp buttonUp answer1 Accept Accept < l 0 txclassname 3DFrame Recessed answerbox1 txclassname 3DFrame Browse Forwards. EnterPage B"one" B"two" B"three" B"four" B"five" B"six" B"seven" B"eight" default LeavePage EnterPage LeavePage EnterPage three seven eight 0,100,0 0,100,0 three 0,100,0 0,100,0 0,100,0 0,100,0 seven 0,100,0 eight 0,100,0 default LeavePage three seven eight 0,100,0 0,100,0 three 0,100,0 0,100,0 0,100,0 0,100,0 seven 0,100,0 eight 0,100,0 Medi-CAL nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnng Unit University of Aberdeenberdeen University of Aberdeenn Hypercalcaemia IIeee txclassname 3DFrame Recessed explain Previous ButtonDown "Browse Backwards." "explain" ButtonDown buttonUp ButtonDown Browse Backwards. explain buttonUp explain ~ defStroke 0,0,0 txClassName button ButtonDown "Return CAL Menu." "explain" X"user" bringWindowToTop( toolbook M"casemenu.tbk" bringwindowtotop( b doesn't even un-iconize 47,119" default ButtonDown buttonUp ButtonDown Return to this CAL Menu. explain buttonUp explain bringWindowToTop sysWindowHandle casemenu.tbk bringwindowtotop set position of mainWindow to 47,119 casemenu.tbk casemenu.tbk default toolbook defStroke 0,0,0 txClassName button Previous ButtonDown "Exit the "explain" "Quit Case Study Two ?"\ f"Yes" SysSuspendMessages ButtonDown buttonUp ButtonDown Exit the application. explain buttonUp Quit Case Study Two ? explain txClassName button defStroke 0,0,0 ButtonDown "explain" ButtonDown buttonUp ButtonDown Go to the first page. explain buttonUp explain txClassName button defStroke 0,0,0 ButtonDown "History." "explain" ButtonDown buttonUp ButtonDown History. explain buttonUp Yhistory explain defStroke 0,0,0 txClassName button "Look up the Help Contents." "explain" contents buttonDown buttonUp buttonDown Look up the Help Contents. explain buttonUp ycontents explain ButtonDown Jvisited "explain" ButtonDown buttonUp ButtonDown Go to last visited page. explain buttonUp explain txClassName button defStroke 0,0,0 ButtonDown Jvisited "explain" ButtonDown buttonUp ButtonDown Go to last visited page. explain buttonUp explain defStroke 0,0,0 txClassName button defStroke 0,0,0 txClassName button The Patient Presents EnterPage default EnterPage EnterPage default A seventy two year old woman is sent up to the clinic with back pain and chest pains. Her GP discovered that she was hypertensive (180/100) some five years previously and has treated her with bendrofluazide 2.5mg/day. The referral letter contains details of blood tests performed by the GP. Your aim is to identify the correct treatment. txclassname 3DFrame Recessed Browse Forwards. MainBackground Cause of Back Pain EnterPage "one" "two" "three" "four" "five" default LeavePage EnterPage LeavePage EnterPage three default LeavePage three Browse Forwards. 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 ? TestOptionText Of course doctors (especially the physicians) never just do one test !! In this patient we also want to find out the cause of the back pain. How would you investigate this? Bone scan CT Scan abdomen X-ray spine iazide levels to see if they are raised Barium enema Bone density Xray spine: Good. The X-ray shows osteopaenia with several collapsed vertebrae. litigation. three CT Scan: No, the clinical history suggests musculo-skeletal pain and other investigations take precedence. Bone density: Not a bad idea, but it would not tell you about the origin of the pain. Osteopaenia (i.e. low bone density) does not cause pain in the absence of fractures. Bone scan: I would do x-ray first. Bone scan is better if you suspect metastases but here we do not.................................... Barium enema: ??**!!??? txclassname 3DFrame Recessed answerbox1 txclassname 3DFrame "one" "two" "three" "four" "five" buttonUp buttonUp three "one" "two" "three" "four" "five" buttonUp buttonUp three "one" "two" "three" "four" "five" buttonUp buttonUp three "one" "two" "three" "four" "five" buttonUp buttonUp three "one" "two" "three" "four" "five" buttonUp buttonUp three Browse Forwards. Relevant Drug Intake Browse Forwards.y HypercalcText Which of the following drug intakes are relevant to hypercalcaemia ? Hint - there are 4 correct choices !????? "Yes, but very rare. One reported Mwas a"&&\ "Californian vegan who lived only on carrot juice."&&\ "Remember retinoic acid derivatives acne!" buttonup buttonup 120,50,100 Yes, but very rare. One reported case was a Californian vegan who lived only on carrot juice. Remember retinoic acid derivatives in acne! Vitamin A "No." buttonup buttonup 0,50,100 Vitamin K "Yes. This obvious cause hypercalcaemia." buttonup buttonup 120,50,100 Yes. This is an obvious cause of hypercalcaemia. Vitamin D Three "Yes - especially Rennies the like, which"&&\ "are 'over counter' treatments often forgotten about."&&\ "These can cause b'milk-alkali' syndrome, r should"&&\ "probably be renamed 'calcium- buttonup buttonup 120,50,100 Yes - especially Rennies and the like, which are 'over the counter' treatments and often forgotten about. These can cause the 'milk-alkali' syndrome, which should probably be renamed the 'calcium-alkali' syndrome. Antacids "Yes, thiazides cause hypercalcaemia Hcausing"&&\ "sodium/ECF volume depletion. This turn said "increase calcium reabsorption Hthe proximal renal tubule."&&\ "For some reason lop diuretics DO NOT buttonup buttonup 120,50,100 Yes, thiazides cause hypercalcaemia by causing sodium/ECF volume depletion. This in turn is said to increase calcium reabsorption by the proximal renal tubule. For some reason lop diuretics DO NOT cause hypercalcaemia. Diuretics "No." buttonup buttonup 0,50,100 Digoxin Eight ,#>b "No." buttonup buttonup 0,50,100 Beta Blockers seven "No." buttonup buttonup 0,50,100 Calcium Antagonists txclassname 3DFrame Recessed answerbox1 txclassname 3DFrame Browse Forwards. three "one" "two" "three" "four" buttonUp buttonUp three alphacheck "answer1" c"PTH" "Yes. Parathyroid Hormone,( correct."&&\ "The ; would be raised. now assaying you will receive results due course." c"serum PTH), response1 "Wrong. You answered" && ". buttonUp buttonUp alphacheck answer1 Yes. Parathyroid Hormone,(PTH), is correct. The PTH would be raised. The lab is now assaying for PTH and you will receive the results in due course. answer1 answer1 serum PTH Yes. Parathyroid Hormone,(PTH), is correct. The PTH would be raised. The lab is now assaying for PTH and you will receive the results in due course. answer1 answer1 serum Parathyroid Hormone Yes. Parathyroid Hormone,(PTH), is correct. The PTH would be raised. The lab is now assaying for PTH and you will receive the results in due course. answer1 answer1 Parathyroid Hormone Yes. Parathyroid Hormone,(PTH), is correct. The PTH would be raised. The lab is now assaying for PTH and you will receive the results in due course. answer1 answer1 Wrong. You answered . Parathyroid Hormone,(PTH), is correct. The PTH would be raised. The lab is now assaying for PTH and you will receive the results in due course. response1 Considering Diagnoses Enterpage B"one" B"two" B"three" B"four" B"five" B"six" default Leavepage Enterpage Leavepage Enterpage three 0,100,0 0,100,0 three 0,100,0 0,100,0 0,100,0 0,100,0 default Leavepage three 0,100,0 0,100,0 three 0,100,0 0,100,0 0,100,0 0,100,0 Accept answer answer1 pthtext How to type in your answer Click in the yellow box and 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 Answer' button. HypercalcText It turns out that, apart from the bendrofluazide, she is on no therapy. Except that is, for Rennies which she takes "on occasion". On closer history taking, it emerges that the back pain was sudden in onset and precipitated by lifting a heavy weight. There is nil to find on examination apart from a mild kyphosis. BP is normal at 150/85. What diagnoses are you considering ? (Hint: at least 2 are possible.)one of which unlikely.) txclassname 3DFrame Recessed "Thiazide could be responsible the hypercalcaemia." buttonup buttonup 120,50,100 Thiazide could be responsible for the hypercalcaemia. Thiazide induced "Unlikely. There nothing exam"&&\ suggest sarcoid." buttonup buttonup 0,50,100 Unlikely. There is nothing in the history or exam to suggest sarcoid. Sarcoid "Very possible otherwise well"&&\ "patient fhypercalcaemia." buttonup buttonup 120,50,100 Very possible in an otherwise well patient with hypercalcaemia. Hyperparathyroidism Three "Possible but unlikely. These patients are almost"&&\ "always alkalotic ( )'s C02 lowish) have"&&\ "renal impairment. They also be taking a "&&\ Rennies etc. (2-3 pkts per day)." buttonup buttonup 60,50,100 Possible but unlikely. These patients are almost always alkalotic (this patient's C02 is lowish) and have renal impairment. They also have to be taking a lot of Rennies etc. (2-3 pkts per day). Milk-alkali syndrome "Unlikely view the negative clinical exam ormal albumin." buttonup buttonup 0,50,100 Unlikely in view of the negative clinical exam and the normal albumin. Cancer "No. These patients are hypotensive usually have other"&&\ "electrolyte abnormalities (low Na, high K)." buttonup buttonup 0,50,100 No. These patients are hypotensive usually and have other electrolyte abnormalities (low Na, high K). Addison's disease answerbox1 txclassname 3DFrame Browse Forwards. Likely Diagnosis after Testing Enterpage B"one" B"two" B"three" B"four" default Leavepage Enterpage Leavepage Enterpage three 0,100,0 0,100,0 three 0,100,0 0,100,0 default Leavepage three 0,100,0 0,100,0 three 0,100,0 0,100,0 Browse Forwards.o Nothing No - some sort of follow up would be indicated. MonitorCalcium Yes - check weekly. Also, think about giving prophylaxis. GiveProphylaxis A good suggestion, although life expectancy of these patients is short and not all will need prophylaxis. Monitoring calcium is also recommended. HypercalcText OK. You have a patient with osteoporosis, fractures and hypercalcaemia. She is also hypertensive. The result of the PTH has just come back and is 8 ng/l (normal 2-8). Her ESR is 10 (normal). What is the likely diagnosis ? by lifting a heavy weight. There is nil to find on examination apart from a mild kyphosis. BP is normal at 150/85. What diagnoses are you considering ? "Rare but possible; PTH levels usually detectable"&&\ sometimes raised condition. Exclude Hmeasurement"&&\ fasting urine ratio calcium/creatinine"&&\ <0.01 suggests FHH)." buttonup buttonup 60,50,100 Rare but possible; PTH levels are usually detectable and sometimes raised in this condition. Exclude by measurement of fasting urine ratio of calcium/creatinine (ratio<0.01 suggests FHH). Familial Hypocalciuric Hypercalcaemia "No. Although a cause unlikely"&&\ %she has a wESR, ( = 10),"&&\ wglobulin." buttonup buttonup 0,50,100 No. Although a cause it is unlikely in this case as she has a normal ESR, (ESR = 10), and normal globulin. Myeloma Three "No. Although a possible cause hypercalcaemia"&&\ "there no clinical evidence Hyperthyroidism." buttonup buttonup 0,50,100 No. Although a possible cause of hypercalcaemia there is no clinical evidence for Hyperthyroidism. Hyperthyroidism B"one" "Almost certainly yes. The PTH )the upper limit innapropriate 'hypercalcaemia, %"&&\ "such indicates parathyroid overactivity. A rare, but"&&\ "possible alternative diagnosis could be familial"&&\ "hypocalciuric buttonup buttonup 120,50,100 Almost certainly yes. The PTH at the upper limit of normal is innapropriate to the hypercalcaemia, and as such indicates parathyroid overactivity. A rare, but possible alternative diagnosis could be familial hypocalciuric hypercalcaemia. Primary hyperparathyroidism txclassname 3DFrame Recessed answerbox1 txclassname 3DFrame Browse Forwards. three 0,100,0 0,100,0 three 0,100,0 0,100,0 default Leavepage three 0,100,0 0,100,0 three 0,100,0 0,100,0 Browse Forwards.o Nothing No - some sort of follow up would be indicated. MonitorCalcium Yes - check weekly. Also, think about giving prophylaxis. GiveProphylaxis A good suggestion, although life expectancy of these patients is short and not all will need prophylaxis. Monitoring calcium is also recommended. HypercalcText OK. You have a patient with osteoporosis, fractures and hypercalcaemia. She is also hypertensive. The result of the PTH has just come back and is 8 ng/l (normal 2-8). Her ESR is 10 (normal). What is the likely diagnosis ? by lifting a heavy weight. There is nil to find on examination apart from a mild kyphosis. BP is normal at 150/85. What diagnoses are you considering ? "Rare but possible; PTH levels usually detectable"&&\ sometimes raised condition. Exclude Hmeasurement"&&\ fasting urine ratio calcium/creatinine"&&\ <0.01 suggests FHH)." buttonup buttonup 60,50,100 Rare but possible; PTH levels are usually detectable and sometimes raised in this condition. Exclude by measurement of fasting urine ratio of calcium/creatinine (ratio<0.01 suggests FHH). Familial Hypocalciuric Hypercalcaemia "No. Although a cause unlikely"&&\ %she has a wESR, ( = 10),"&&\ wglobulin." buttonup buttonup 0,50,100 No. Although a cause it is unlikely in this case as she has a normal ESR, (ESR = 10), and normal globulin. Myeloma Three "No. Although a possible cause hypercalcaemia"&&\ "there no clinical evidence Hyperthyroidism." buttonup buttonup 0,50,100 No. Although a possible cause of hypercalcaemia there is no clinical evidence for Hyperthyroidism. Hyperthyroidism B"one" "Almost certainly yes. The PTH )the upper limit innapropriate 'hypercalcaemia, %"&&\ "such indicates parathyroid overactivity. A rare, but"&&\ "possible alternative diagnosis could be familial"&&\ "hypocalciuric buttonup buttonup 120,50,100 Almost certainly yes. The PTH at the upper limit of normal is innapropriate to the hypercalcaemia, and as such indicates parathyroid overactivity. A rare, but possible alternative diagnosis could be familial hypocalciuric hypercalcaemia. Primary hyperparathyroidism txclassname 3DFrame Recessed answerbox1 txclassname 3DFrame Results Browse Backwards. default LeavePage enterPage LeavePage enterPage default LeavePage Na 145 Urea 6.5 Creat 100 Alk P 80 ggt GGT 24 Albumin 45 Globulin 28 Calcium 2.85 AST 24 CO2 25 K 3.4 Bil 12 Phosphate 0.8 mmol/l "Sorry, try buttonUp buttonUp Sorry, try again "Sorry, try buttonUp buttonUp Sorry, try again "Yes, the serum calcium slightly elevated."&&\ "None 0other tests are relevant Lproblem." buttonUp buttonUp Yes, the serum calcium is slightly elevated. None of the other tests are relevant to the problem. typed Na 145 K 3.4 CO2 25 Urea 6.5 Creat 100 AST 24 Bil 12 ALkP 80 GGT 24 Albumin 45 Calcium 2.85 Globulin 28 Phosphate 0.8 mmol/ll "Yes, the serum calcium slightly elevated."&&\ "None .other results are relevant Lproblem." buttonUp buttonUp Yes, the serum calcium is slightly elevated. None of the other results are relevant to the problem. "Sorry, try buttonUp buttonUp Sorry, try again "Sorry, try buttonUp buttonUp Sorry, try again typedhelp Look at the original letter.. handwriting by clicking here. HelpButton "hand" "handhelp" "Typed" "Typedhelp" False default buttonUp buttonUp handhelp Typed Typedhelp default HelpButton2 "hand" "Typed" B"helpbutton" False default buttonUp buttonUp Typed helpbutton default Look at the blood results which he has written on the back of the letter. Click on the result(s) which might be relevant to the problem.. txclassname 3DFrame Recessed EnterPage "explain" default LeavePage EnterPage LeavePage EnterPage explain default LeavePage HelpButton "hand" "handhelp" "Typed" "Typedhelp" False default buttonUp buttonUp handhelp Typed Typedhelp default txclassname 3DFrame Recessed Browse Backwards. Thiazide Experiment Results Enterpage B"one" B"two" default Leavepage Enterpage Leavepage Enterpage 0,100,0 0,100,0 default Leavepage 0,100,0 0,100,0 Browse Forwards.W You stop the thiazide and see the patient in 4 weeks. Her blood pressure is now 160/105. Look at the blood results. 5 mmol/l; K 3.9 mmol/l; C02 25; Urea 4.5 mmol/l; Creat 90 mol/l, Albumin 46 g/l; Calcium 2.9 mmol/l; phosphate 0.75 mmol/l now ? (you may choose to do more than just one thing). Was it the thiazide causing the hypercalcaemia ? "Correct, since was"&&\ "controlling &hypertension." buttonup buttonup 120,50,100 Correct, put her back on it since it was controlling her hypertension. "Wrong, you should since was"&&\ "controlling &hypertension." buttonup buttonup 0,50,100 Wrong, you should put her back on it since it was controlling her hypertension. New Results: BP 160/105 Na 145 mmol/l K 3.9 mmol/l C02 25 Urea 4.5 mmol/l Creat 90 mol/l Albumin 46 g/l Calcium 2.9 mmol/l Phosphate 0.75 mmol/llllllll' Original Results: BP 150/85 Na 145 mmol/l K 3.4 mmol/l C02 25 Urea 6.5 mmol/l Creat 100 mol/l Albumin 45 g/l Calcium 2.85 mmol/l; Phosphate 0.8 mmol/lll txclassname 3DFrame Recessed answerbox1 txclassname 3DFrame Browse Forwards. seven "No." buttonup buttonup 0,50,100 Calcium Antagonists txclassname 3DFrame Recessed answerbox1 txclassname 3DFrame Browse Backwards. Possible Thiazide Involvement EnterPage three default LeavePage EnterPage LeavePage EnterPage default three LeavePage three Browse Forwards.i pthrp Accept answer answer2 pthrptext How to type in your answer Click in the yellow box and type the name of the other factor (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 Answer' button. ick on the 'Accept Answer' button. on. TestOptionText The possible diagnoses are Milk-Alkalai syndrome, (unlikely), hyperparathyroidism, (possible), and thiazide induced, (possible). How would you investigate the possible involvement of thiazide ? ? his further? Check urine calcium Stop treatment to see what happens "one" "two" "three" "four" buttonUp buttonUp three Check serum thiazide levels to see if they are raised Check PTH Serum thiazide: No. a good lawyer - you'll need one for the GMC hearing and the litigation. Urine calcium: Not useful unless you suspect familial hypocalciuric hypercalcaemia.nt in hypercalcaemia. three Stop treatment: Yes - and repeat calcium after 2-4 weeks. See also 'Check PTH'.... PTH: Yes - it would be low in true thiazide hypercalcaemia. I would try stopping the drug first though. See also 'Stop treatment'. txclassname 3DFrame Recessed answerbox1 txclassname 3DFrame "one" "two" "three" "four" buttonUp buttonUp three "one" "two" "three" "four" buttonUp buttonUp three "one" "two" "three" "four" buttonUp buttonUp three Browse Forwards. MainBackground Medi-CAL nnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnng Unit University of Aberdeenberdeen University of Aberdeen Hypercalcaemia IIeee txclassname 3DFrame Recessed explain ButtonDown "Browse Forwards." "explain" ButtonDown buttonUp ButtonDown Browse Forwards. explain buttonUp explain ~ r defStroke 0,0,0 txClassName button Previous ButtonDown "Browse Backwards." "explain" ButtonDown buttonUp ButtonDown Browse Backwards. explain buttonUp explain defStroke 0,0,0 txClassName button ButtonDown "Return CAL Menu." "explain" X"user" bringWindowToTop( toolbook M"casemenu.tbk" bringwindowtotop( b doesn't even un-iconize 47,119" default ButtonDown buttonUp ButtonDown Return to this CAL Menu. explain buttonUp explain bringWindowToTop sysWindowHandle casemenu.tbk bringwindowtotop set position of mainWindow to 47,119 casemenu.tbk casemenu.tbk default toolbook defStroke 0,0,0 txClassName button Previous ButtonDown "Exit the "explain" "Quit Case Study Two ?"\ f"Yes" SysSuspendMessages ButtonDown buttonUp ButtonDown Exit the application. explain buttonUp Quit Case Study Two ? explain txClassName button defStroke 0,0,0 ButtonDown "explain" ButtonDown buttonUp ButtonDown Go to the first page. explain buttonUp explain txClassName button defStroke 0,0,0 ButtonDown "History." 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