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Fluid, Electrolyte and Acid-Base Disorders_ Clinical Evaluation and Management > hypercalcemia and related disorders Mnemonics > Flashcards

hypercalcemia and related disorders Mnemonics Flashcards

1
Q

What does ‘PTH High’ indicate in hypercalcemia diagnostics?

A

Primary hyperparathyroidism (PHPT)

Indicates a condition where the parathyroid gland is overactive, leading to elevated calcium levels.

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2
Q

What does ‘PTH Low’ signify in the context of hypercalcemia?

A

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.

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3
Q

Which conditions are associated with ‘PTH Mid’ levels?

A

Lithium effect, Familial hypocalciuric hypercalcemia (FHH)

These conditions can lead to ambiguous PTH levels, complicating diagnosis.

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4
Q

What mnemonic is used to categorize types of malignancy-related hypercalcemia?

A

P-L-O-T

Represents PTHrP-mediated, Local osteolysis, 1,25(OH)₂D₃, and True ectopic PTH.

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5
Q

What does the treatment ladder ‘3-2-1 Protocol’ involve?

A

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.

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6
Q

What are the urine calcium rules for differentiating FHH from PHPT?

A

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.

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7
Q

What does the mnemonic ‘VITAMIN D’ represent in granulomatous causes of hypercalcemia?

A

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.

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8
Q

What are the red flags for Milk-Alkali Syndrome represented by the mnemonic ‘CASH’?

A

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.

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9
Q

What ECG changes are associated with hypercalcemia?

A

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.

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10
Q

What precautions should be taken when administering bisphosphonates, summarized by ‘RENAL’?

A

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.

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11
Q

What are the symptoms of hypercalcemia summarized by ‘Stones, Bones, Groans, Moans, Thrones, Psychiatric Overtones’?

A

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.

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12
Q

What are the primary lab findings in primary hyperparathyroidism?

A

High calcium
Low phosphate
High PTH

Essential for diagnosing primary hyperparathyroidism.

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13
Q

What does the mnemonic ‘ABCDE’ represent in the treatment approach for hypercalcemia?

A

A - Aggressive IV fluids
B - Bisphosphonates
C - Calcitonin
D - Discontinue offending drugs
E - Eliminate calcium intake

A structured approach to managing hypercalcemia effectively.

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14
Q

What does the mnemonic ‘CHIMPANZEES’ stand for in causes of hypercalcemia?

A

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.

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15
Q

True or False: Calcitonin works in hours, while bisphosphonates work in days.

A

True

Important to consider when treating severe cases of hypercalcemia.

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16
Q

What is the significance of the statement ‘FHH is benign but looks like PHPT’?

A

Genetic testing prevents unnecessary surgery

Highlights the importance of differentiating between familial hypocalciuric hypercalcemia and primary hyperparathyroidism.

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17
Q

Fill in the blank: ‘PTHrP mimics ______ but kills vitamin D.’

A

[PTH]

Explains the biochemical relationship between PTHrP and vitamin D metabolism.

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18
Q

What does the mnemonic CHIMPANZEES represent in relation to hypercalcemia causes?

A

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

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19
Q

What are the symptoms of hypercalcemia represented by the mnemonic Stones, Bones, Groans, Moans, Thrones, Psychiatric Overtones?

A
  • Stones - Nephrolithiasis
  • Bones - Osteoporosis/pain
  • Groans - GI (nausea, constipation)
  • Moans - Fatigue/malaise
  • Thrones - Polyuria (nephrogenic DI)
  • Psychiatric - Confusion, depression

Best for recognizing hypercalcemia presentations

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20
Q

What are the classic lab findings in primary hyperparathyroidism represented by the mnemonic High-Low-High?

A
  • High calcium
  • Low phosphate
  • High PTH

Best for classic lab findings in primary hyperparathyroidism

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21
Q

What does the mnemonic PLOT represent in the context of malignancy mechanisms causing hypercalcemia?

A
  • P - PTHrP (humoral)
  • L - Local osteolysis
  • O - 1,25(OH)₂D₃ (lymphomas)
  • T - Tumor ectopic PTH

Best for categorizing cancer-related hypercalcemia

22
Q

What are the granulomatous causes of hypercalcemia represented by the mnemonic STAR?

A
  • S - Sarcoidosis
  • T - Tuberculosis
  • A - AIDS-related
  • R - Rheumatoid nodules

Best for remembering granuloma-associated hypercalcemia

23
Q

What are the treatment steps for hypercalcemia represented by the mnemonic ABCDE?

A
  • A - Aggressive IV fluids
  • B - Bisphosphonates
  • C - Calcitonin
  • D - Discontinue triggers
  • E - Eliminate calcium intake

Best for acute management steps

24
Q

What are the key differences between FHH and PHPT?

A
  • FHH:
    • Familial
    • Hypocalciuria (Ca/Cr <0.01)
    • High Mg²⁺
  • PHPT:
    • Primary
    • Hypercalciuria (Ca/Cr >0.02)
    • PTH elevated

Best for differentiating these similar conditions

25
What is the Milk-Alkali syndrome triad represented by the mnemonic ABC?
* A - Alkalosis * B - BUN elevated * C - Calcium high ## Footnote Best for remembering the classic triad
26
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 ## Footnote Clinical pearl: Always check ionized calcium if albumin is abnormal
27
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) ## Footnote Best for oncology boards or tumor boards
28
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 ## Footnote ER protocol: This sequence prevents rebound hypercalcemia
29
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) ## Footnote Key point: Steroids work for all except coccidioidomycosis
30
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 ## Footnote Updated guideline: Asymptomatic patients may not need surgery
31
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 ## Footnote Modern variant: Calcium carbonate + PPIs
32
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) ## Footnote Critical sign: QRS >140ms requires emergent calcium-lowering
33
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⁺) ## Footnote Safety tip: Hydrate with 500 mL NS pre-infusion
34
True or False: PTH tells the story in hypercalcemia diagnosis.
True ## Footnote High PTH = Primary hyperparathyroidism; Low PTH = Look for malignancy/granulomas
35
True or False: FHH is benign and requires treatment.
False ## Footnote FHH is familial, benign, and needs no treatment. Genetic testing prevents unnecessary surgery.
36
Fill in the blank: Calcitonin works in ______, bisphosphonates in ______.
hours; days ## Footnote Use together for Ca >13 mg/dL
37
What is a key point regarding steroids in granulomatous disease?
Steroids are diagnostic and therapeutic ## Footnote Trial in suspected granulomatous disease
38
What should be checked before surgical intervention in hypercalcemia?
Check urine calcium ## Footnote Essential to distinguish FHH from PHPT
39
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 ## Footnote Always screen for MEN1 in young PHPT patients (pancreatic NET, pituitary tumors)
40
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 ## Footnote Check 24,25(OH)₂D₃ to distinguish true vitamin D toxicity
41
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) ## Footnote Always rule out thyroid nodules pre-parathyroidectomy
42
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) ## Footnote Vitamin D repletion may lower PTH in PHPT (maintain 25(OH)D >20 ng/mL)
43
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) ## Footnote Intraoperative PTH monitoring is mandatory (50% drop at 10 mins)
44
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 ## Footnote Diagnostic gold standard: CaSR gene testing
45
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 ## Footnote Check calcium q3mo in chronic users
46
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 ## Footnote 3.5 gland removal preferred
47
What is 'Hungry bone syndrome' in relation to postoperative care?
Expect profound hypocalcemia post-PTX in severe osteitis fibrosa (have IV calcium ready) ## Footnote This condition can occur after parathyroidectomy due to rapid bone mineralization.
48
True or False: PTHrP and PTH are the same.
False ## Footnote Order intact PTH and PTHrP simultaneously to avoid assay cross-reactivity.
49
What is required for diagnosing 'Non-classical PHPT'?
3 elevated PTH measurements + exclude causes ## Footnote This variant presents with normal calcium levels.
50
What should be done in a genetic testing cascade for FHH?
Screen all FHH probands' families for CaSR mutations ## Footnote This helps in identifying at-risk individuals.
51
What is the recommendation for PHPT with eGFR <60?
May benefit from early surgery regardless of symptoms ## Footnote Early intervention can prevent complications related to hyperparathyroidism.

Fluid, Electrolyte and Acid-Base Disorders_ Clinical Evaluation and Management (42 decks)

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