Miscellaneous

Question 1

What is the normal range for serum calcium in the body?

Answer 1

2.2 - 2.6 mmol

Question 2

What are the categories of causes of Hypercalcaemia?

Answer 2

Parathyroid related

Non parathyroid related

Question 3

What are the parathyroid causes of Hypercalcaemia?

Answer 3

Hyperparathyroidism (primary or tertiary)

Question 4

What are the non parathyroid related causes of Hypercalcaemia?

Answer 4

Malignancy (myeloma or bony mets)
CKD
Vit D intoxication
Addisons
Drugs
Immobilisation
Familial hypocalciuric Hypercalcaemia
Sarcoidosis

Question 5

What medications can cause Hypercalcaemia?

Answer 5

Thiazides
Lithium
Cisplatin

Question 6

What is primary Hyperparathyroidism ?

Answer 6

Tumour of the parathyroid glands leads to uncontrolled production of PTH

Question 7

What cells produce PTH?

Answer 7

Chief cells

Question 8

What is the function of PTH?

Answer 8

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

Question 9

What is secondary hyperparathyroidism?

Answer 9

When patient has CKD the levels of calcium are low, this stimulates the parathyroid gland to increase its activity to counteract this

Question 10

How does secondary hyperparathyroidism affect serum calcium levels?

Answer 10

Typically normal (doesn’t become high)

Question 11

What is tertiary hyperparathyroidism?

Answer 11

When the parathyroid glands undergo hyperplasia from being overactive with Secondary hyperparathyroidism

Question 12

How does Hypercalcaemia present?

Answer 12

Bones groans thrones stones and psychic moans:
-constipation
-N+V
-renal stones
-fatigue
-depression
-psychosis
-anorexia

Question 13

What are some complications of Hypercalcaemia?

Answer 13

Renal stones
Osteoporosis
Pancreatitis
Glaucoma

Question 14

What are important investigations when investigating a Hypercalcaemia?

Answer 14

FBC
U+Es
PTH LEVELS
TFT
Cortisol
Vit D
Myeloma screen

Question 15

Which investigations is most important for Hypercalcaemia?

Answer 15

PTH levels

Question 16

Why is it important to measure PTH levels with Hypercalcaemia?

Answer 16

Parathyroid issue or not

If PTH = elevated is parathyroid issue
If PTH not elevated MOST LIKELY MALIGNANCY

Question 17

When the patients PTH is elevated when they have Hypercalcaemia, what is the next step investigation?

Answer 17

Urinary calcium creatinine clearance ratio

Question 18

What is the relevance of measuring urinary calcium creatinine clearnce ratio in a patient with Hypercalcaemia whos PTH is elevated?

Answer 18

Determine whether it’s primary hyperparathyroidism or Familial hypocalciuric Hypercalcaemia

Question 19

What urinary calcium creatinine clearance ratio indicates Familial Hypocalciuric Hypercalcaemia?

Answer 19

LOW RATIO/ low calcium in urine

Question 20

What urinary calcium creatinine clearance ratio indicates primary hyperparathyroidism?

Answer 20

High ratio/ lots of calcium in urine

Question 21

When a patient has Hypercalcaemia and their PTH is not elevated, what are you thinking and what imaging would you use?

Answer 21

? Malignancy

CT CAP
Also could image parathyroid

Question 22

What is the treatment for Hypercalcaemia caused by familial hypocalciuric Hypercalcaemia?

Answer 22

Doesn’t require treatment

Question 23

What is the gold standard treatment for a patient with Hypercalcaemia caused by primary hyperparathyroidism?

Answer 23

Parathyroidectomy / surgical removal of adenoma

Question 24

What is the criteria for treating a patient with Hypercalcaemia caused by primary hyperparathyroidism with a parathyroidectomy?

Answer 24

Ca2+ > 3mmol
Age < 50
T score < -2.5

Question 25

What investigation would you need to do so you can work out if a patient is eligible for a parathyroidectomy with primary hyperparathyroidism?

Answer 25

DEXA scan for T score

Question 26

If a patient is not eligible for a parathyroidectomy when they have Hypercalcaemia what is the next most suitable options?

Answer 26

Medication

Question 27

What medication can be given for second line treatment for Hypercalcaemia caused by primary hyperparathyroidism?

Answer 27

Cinacalcet + Bisphosphonates and or HRT

Question 28

What is considered emergency Hypercalcaemia?

Answer 28

Ca2+>3.5mmol

Question 29

What is the treatment for emergency Hypercalcaemia?

Answer 29

Vigorously hydrate 200-500ml/hr (3-6L over 24hrs) Once volume depleted give bisphosphonates

Question 30

What is considered hypocalcaemia?

Answer 30

Ca2+ < 2.2mmol

Question 31

What are the categories off causes of Hypocalcaemia?

Answer 31

Parathyroid related Non parathyroid related

Question 32

What are the parathyroid causes of Hypocalcaemia?

Answer 32

Hypoparathyroidism Iatrogenic Hypoparathyroidism (Surgery, radiation, infiltration)

Question 33

What are the non parathyroid related causes of Hypocalcaemia?

Answer 33

Vitamin D deficiency CKD Magnesium deficiency GI absorption issues (coeliacs, Crohns) Drugs Osteoblastic metastases (prostate)

Question 34

What drugs can cause hypocalcaemia?

Answer 34

Calcitonin Cisplatin Phosphate Citrates

Question 35

How does Hypocalcaemia present?

Answer 35

Seizures Cramps Tingling/numbness Tetany Strider

Question 36

What are the 2 signs that indicate Hypocalcaemia?

Answer 36

Chvosteks sign Trousseaus sign

Question 37

What is chvosteks sign?

Answer 37

Tapping on the facial muscles causes Ipsilateral twitching of the facial muscle Indicate hypocalcaemia

Question 38

What is Trosseaus sign?

Answer 38

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

Question 39

How do you investigate a patient with Hypocalcaemia?

Answer 39

FBC U+E + urine dip PTH LEVELS Vit D levels Amylase Mg levels

Question 40

How do you manage hypocalcaemia?

Answer 40

Calcium supplements Keeping calcium below normal range Vitamin D supplements

Question 41

Why do you keep calcium just bellow normal range in a patient whos had Hypocalcaemia?

Answer 41

Prevents high calcium in urine and so helps prevent urinary tract stone formation

Question 42

What is considered emergency Hypocalcaemia?

Answer 42

Ca2+ < 1.9mmol

Question 43

What is the emergency treatment of emergency hypocalcaemia?

Answer 43

IV 10-20ml 10% Calcium gluconate in 200ml saline in 10mins and repeat when necessary Check calcium 6hrly

Question 44

What are the severe complications of acute hypocalcaemia?

Answer 44

Seizures Laryngeal spasm Prolonged QT syndrome (VT -> VF)

Question 45

What is thr long term management of hypocalcaemia?

Answer 45

Calcium supplements Vit D Mg if needed Monitor Ca2+, Phospphate and Mg every 3-6months

Question 46

What is considered hyponatraemia?

Answer 46

Na+ < 133

Question 47

What is the ranking of severity of hyponatraemia?

Answer 47

Mild 127 - 132 Moderate 121 -126 Severe <. 120

Question 48

What are the 3 categories of causes of hyponatraemia?

Answer 48

Hypervolaemic Euovolaemic Hypovolaemic

Question 49

What are some hypervolaemic causes of hyponatraemia?

Answer 49

Dilutional: -CKD -CHF -Liver cirrhosis -Nephrotic syndromes

Question 50

What are some euovolaemic causes of hyponatraemia?

Answer 50

SIADH Medications Glucocorticoid deficiency Severe hypothyroidism

Question 51

What medications can cause hyponatraemia?

Answer 51

Thiazides diuretics Loop diuretics K+ sparring diuretics ARBs (candesartan) PPIs (omeprazole) SSRIs

Question 52

What are some hypovolaemic causes of hyponatraemia?

Answer 52

GI losses (N+V) Burns Sweating Addisons disease

Question 53

What is a common cause of hyponatraemia?

Answer 53

Pseudo

Question 54

How is hypovolaemic hyponatraemia manage?

Answer 54

IV 0.9%NaCl

Question 55

How is Euovolaemic hyponatraemia managed?

Answer 55

Rule out addisons, thyroid issues then SIADH

Question 56

How do you investigate a hyponatraemia?

Answer 56

U+Es Serum osmolality Urine osmolality Urine Na+ TFTs Cortisol and ACTH levels

Question 57

What is the management for hypervolaemic hyponatraemia?

Answer 57

Fluid restriction (<1.5L per day) Diuretics

Question 58

How is SIADH diagnosed?

Answer 58

Serum osmolality < 275mosm/kg Urine osmolality > 100 Urine Na+ > 30mmol Clinically euovolaemic

Question 59

How is hyponatraemia caused by SIADH managed?

Answer 59

Fluid restriction < 1.5L per day + Demeclocycline

Question 60

How does demeclocycline work in treating SIADH?

Answer 60

Causes Nephrogenic diabetes Insipidus to prevent kidney responding to the high levels of ADH

Question 61

How quickly should sodium be corrected in a pateitn with mild moderate hyponatraemia?

Answer 61

0.5mmol/hr

Question 62

What is the max correction of sodium in hyponatraemia that should be done in 24hrs and why?

Answer 62

8-10mmol Risk of Osmotic demyelination syndrome

Question 63

What is the severe complication of rapid correction of hyponatraemia?

Answer 63

Central pontine demyelinosis/ osmotic demyelination syndrome

Question 64

How does hyponatraemia present?

Answer 64

Headaches Nausea + vomiting Fatigue Confusion Muscle cramps Cerebral odema Hyporeflexia Respiratory arrest

Question 65

What is the management of severe hyponatraemia?

Answer 65

IV 150ml 3% NaCl 20mins Repeat 2. More times or until 5mmol/L increase in Na+

Question 66

How does central pontine myelinosis or osmotic demyelination syndrome present?

Answer 66

Locked in syndrome Dysphagia

Question 67

What is considered severe/emergency hyponatraemia?

Answer 67

Na+ <120mmol

Question 68

How does hypernatraemia present?

Answer 68

Thirst Irritability Muscle weakness Confusion Seizures Coma

Question 69

What is the management for hypernatraemia?

Answer 69

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

Question 70

What hormones do the ovaries make?

Answer 70

Testosterone Androstenedione

Question 71

What sex hormones do the adrenal glands make?

Answer 71

DHEA

Question 72

What are some causes of hyperandrogenism?

Answer 72

PCOS Ovarian cancer CAH Cushings Acromegaly Adrenal adenoma

Question 73

How does hyperandrogenism present?

Answer 73

Hirsutism Acne Signs of virilisation: -frontal balding -deep voice -inc muscle mass -clitoromegaly

Question 74

What is primary amenorrhoea?

Answer 74

Failure to menstruate / menarche by 16

Question 75

What is secondary amenorrhoea?

Answer 75

Had menses but ceased for 6months or more

Question 76

What is oligomenorrhoea?

Answer 76

Less than 9 periods a year

Question 77

What is primary hypogonadism?

Answer 77

Issue with th ovaries

Question 78

What is secondary hypogonadism?

Answer 78

Issue with pituitary or hypothalamus which affects the ovaries

Question 79

What hypothalamic issues can cause secondary hypogonadism?

Answer 79

Stress Exercise Weight loss Kallmans syndrome

Question 80

What pituitary issues can cause secondary hypogondism?

Answer 80

Autoimmune Drugs Cushings Hyperprolactinaemia Sheehans syndrome

Question 81

What is Multiple Endocrine Neoplasia (MEN)?

Answer 81

Autosomal dominant mutations

Question 82

What is MEN1 and what is its triad?

Answer 82

Autosomal dominatn mutation on chromosome 11 Pituitary adenoma Parathyroid hyperplasia Pancreatic tumour

Question 83

What chromosome is affected with MEN2?

Answer 83

Autosomal dominatn mutation on chromosome 10

Question 84

What investigations should be done for amenorrhoea?

Answer 84

Pregnancy test LH FSH Prolactin

Question 85

What testosterone, LH and FSH levels will be measured with Kallmans syndrome?

Answer 85

Kallman = low man All will be low Test = low LH = low FSH = low