🥵 HARD

Challenge yourself on this harder set of questions on hyper and hypocalcaemia 

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Approach to calcium disturbance

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Question 1

Stem 1, question 1 of 3

A patient is brought into the emergency department with paraesthesia and seizures. On examination the patient has brittle nails with transverse grooves, dermatitis and hyperpigmentation.

When taking the patient's blood pressure the patient has a carpopedal spasm with the metacarpophalangeal joints flexing the interphalageal joints extending. What causes this to occur?
A
The restriction of blood flow is deleterious to the function of excitable membranes which leads to skeletal muscle fatigue
B
In the absence of blood flow, the hypercalcaemic state and subsequent neuromuscular irritability will induce a spam of the muscles of the hand and forearm
C
The restriction of blood flow leads to neuromuscular irritability which causes a spasm of the hand and forearm
D
The restriction of blood flow leads to hypercalcaemia and causes extension of the hand and forearm
E
In the absence of blood flow, the hypocalacaemic state and subsequent neuromuscular irritability will induce a spam of the muscles of the hand and forearm
Question 1 Explanation: 
This is a bit of a tricky one so don't worry if you became stuck. The initial question stem is describing the clinical features of HYPOcalcaemia and the question itself is describing Trousseu's sign (a sign of hypocalcaemia). Trosseau's sign occurs in the absence of blood flow, in this context caused by the inflation of the blood pressure cuff, the hypocalcaemia and subsequent neuromuscular irritability will induce a spasm of the muscles of the hand and forearm.
Question 2

Stem 1, question 2 of 3

Urgent electrolyte blood tests are performed and reveal the following results: Low albumin-corrected serum total calcium and high serum phosphate. All other blood test are within normal range. What is the cause of the hypocalcaemia in this patient?
A
Malabsorption
B
Chronic renal failure
C
Hypoparathryoidism
D
Hyperparathryoidism
E
Sarcoidsis
Question 2 Explanation: 
HYPOparathyroidism is caused by a relative or absolute deficiency of plasma parathyroid hormone. This leads to a low serum calcium level (less stimulation of calcitriol to cause calcium reabsorption) and elevated serum phosphate due to a reduction in phosphate excretion. Malabsorption and chronic renal failure will also cause hypocalcaemia, but will not have further blood test abnormalities. Hyperparathryoidism and sarcoidosis result in HYPERcalacaemia.
Question 3

Stem 1, question 3 of 3

The patient successfully is treated and is advised to eat a calcium rich diet. Which of the following foods is NOT rich in calcium?
A
Sardines
B
Spinach
C
Cheese
D
Vegetable oil
E
Fortified soya drinks
Question 3 Explanation: 
Vegetable oil is not a source of calcium but a great source of vitamin E. All of the others are good sources of calcium. This is a great resource to use: https://www.nhs.uk/conditions/vitamins-and-minerals/
Question 4

Stem 2, question 1 of 6

A 78 year old presents to their GP with a 2 week history of lethargy, confusion,  fatigue, constipation, polyuria, abdominal pain and nausea. Past medical history includes renal cell carcinoma 2 years previously.

What is most likely to be causing this presentation?
A
Dehydration
B
Dietary supplements
C
Humoral hypercalcaemia
D
Sarcoidosis
E
Tuberculosis
Question 4 Explanation: 
This patient is presenting with the clinical features of acute onset of hypercalcaemia. Hypercalcaemia is deleterious to the function of excitable membranes leading to skeletal muscles and gastrointestinal smooth muscle fatigue. All of the answers are causes of hypercalcaemia however, given the history of renal cell carcinoma and the acute onset of symptoms this is more likely to be a hypercalcaemia of malignancy. Hypercalcaemia of malignancy is split into two types: Osteolytic hypercalcaemia and humeral hypercalcaemia. Humeral hypercalcaemia occurs as a result of tumour secretion of parathyroid hormone related peptide which leads to activation of oesteoclastic bone resorption and suppression of osteoblastic bone formation.
Question 5

Stem 2, question 2 of 6

An ECG is performed. What ECG changes are seen in hypercalcaemia?
A
Tented T waves
B
Long QT interval
C
ST segment elevation
D
U wave
E
Short QT interval
Question 5 Explanation: 
A short QT interval is seen in hypercalcaemia and results in an increased risk of cardiac arrest. Tented T waves are seen hyperkalaemia, long QT is seen in hypocalcaemia. ST segment elevation is seen in ischaemia. U waves are seen with delayed repolarisation.
Question 6

Stem 2, question 3 of 6

If the main presentation was recurrent renal stones, what is the likely cause for hypercalcaemia?
A
Lithium use
B
Hyperparathyroidism
C
Tuberculosis
D
Multiple myeloma
E
Dehydration
Question 6 Explanation: 
Renal stones are a typical manifestation of hyperparathyroidism as the cause for hypercalcaemia. The other answer options will present with more generalised symptoms of hypercalcaemia.
Question 7

Stem 2, question 4 of 6

The patient mentions their friend was recently diagnosed with multiple myeloma, how can multiple myeloma cause hypercalcaemia?
A
Decreased osteolytic bone activity causing an decreased release of phosphorus from the bone
B
Decreased osteoblast activity causing an increased release of calcium from the bone
C
Increased osteolytic bone activity causing an increased release of calcium from the bone
D
Increased osteoblast activity caused increased release of calcium from the bone
E
Increased osteolytic activity causing a decreased release of calcium from the bone
Question 7 Explanation: 
Multiple myeloma is a disease associated with osteolytic bone disease, causing an increased release of calcium form the bone, thus leading to hypercalcaemia
Question 8

Stem 2, question 5 of 6

To treat the hypercalcaemia, the patient is given calcitonin. How does calcitonin reduce calcium levels?
A
Increase urinary excretion of calcium in the loop of Henle
B
Inhibits osteoclast activity and enhance urinary excretion of calcium
C
Dilute calcium levels by increasing plasma volume
D
Inhibits osteoblast activity and enhance urinary excretion of calcium
E
Restoration of vitamin D levels
Question 8 Explanation: 
Calcitonin inhibits the mobilisation of calcium from the bones and increases urinary excretion and so reduces calcium levels. Fluids will dilute calcium levels and loop diuretics will help to enhance urinary excretion of calcium
Question 9

Stem 2, question 6 of 6

Pulmonary tuberculosis can result in hypercalcaemia, by which mechanism does this occur?
A
Secretion of parathyroid hormone related peptide leading to activation osteoclastic bone resorption
B
Excessive vitamin D intake
C
Poor absorption of calcium from the gut
D
Defect in activation of parathyroid hormone receptor
E
Excessive extra-renal 1-alpha hydroxylase activity
Question 9 Explanation: 
Tuberculosis causes hypercalcaemia due to a excessive extra-renal 1-alpha hydroxylase activity, this results in increased calcium reabsorption thus leading to hypercalcaemia
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