iCase Report

on Stephen Ujano
Hypocalcemia PGI
 Objectives
General:
To present and discuss a case of a patient with a secondary hypocalcemia

Specific:
1. To define hypocalcemia
2. To discuss the approach to a patient with hypocalcemia
2. To discuss the physiological role of parathyroid hormone in calcium
homeostasis, role of calcium and the pathophysiological effects of hypocalcemia in
the body
3. To enumerate the different etiology of hypocalcemia
4. To define and discuss post-operative hypoparathyroidism
5. To discuss and explain the principles of managing hypocalcemia
 General Data

• A.S.
• 44/F
• Married
• Filipino
• Roman Catholic
• Brgy. 27, Laoag City, I.N.
 History of Present Illness
• Diagnosed case of • Interval History • 6 hours PTA
Hypertension since – Episodic muscle – (+) generalized muscle
2016 spasms and spasm more on the
– Telmisartan 40 mg OD, paresthesia with upper extremities but
good compliance spontaneous still tolerable
• Underwent Total resolution after intake – Took maintenance
Thyroidectomy for of medications meds
Multinodular Nontoxic – No resolution of
Goiter last May 2018 in – No fever symptoms
MMMHMC – No bipedal edema
• Hypocalcemic post- – No seizures • 2 hours PTA
operatively
– No trauma – Generalized muscle
– Calcitriol OD, Calcium + spasm
Vit. D3 + Minerals 2 – No abdominal pain
– No jaundice – Difficulty mobilizing all
tabs TID and
extremities
Levothyroxine 125 mcg – No headache
tab OD MWF, 112.5 mg – No dyspnea,
– No loss of
tab TThSS compliant dysphagia, dysphonia
consciousness
with regular ff-ups – Consult
– No recent injury
– Admission
 History
• Past Medical:
• S/P Appendectomy 2008
• S/P Total thyroidectomy for MNTG (May 2018) on Levothyroxine 125 mg tab
OD
• Hypertension St. II on Telmisartan 40 mg OD

• OB-Gyn:
• G2P2 (2002)
• LMP: Sept. 9, 2018

• Family History:
• Hypertension – parents
• Stroke – Father

• Social and Environmental:

• No exposure to toxic substances
• No vices
 Review of Systems
• General: (-) body weakness, (-) fatigue, (-) weight loss, (-) chills, (-) diaphoresis, (-) dizziness
• Integumentary:(-) rash, (-) sores, (-) hives,
• Head and Neck: (-) pain, (-) stiffness
Eyes: (-) pain, (-) diplopia, (-) visual dysfunction, (-) dryness, (-) redness, (-) tearing
Ears: (-) difficulty hearing, (-) tinnitus, (-) pain, (-) discharge
Nose: (-) epistaxis, (-) discharge, (-) smell dysfunction, (-) sneezing
Mouth: (-) soreness, (-) hoarseness, (-) cyanosis, (-) change in tone of voice
• Respiratory:(-) cough, (-) hemoptysis, (-) wheezing, (-) occupational exposure, (-) TB
• Cardiac:(-) chest pains/ discomfort, (-) orthopnea, (-) palpitation,
• (-) undue fatigue, (-) edema, (-) cyanosis, (-) syncope
• Vascular:(-) intermittent claudication (-) varicosities
• GIT: (-) vomiting, (-) nausea, (-) hematemesis, (-) indigestion, (-) melena, (-) hematochezia,
• (-) heartburn, (-) abdominal distention, (-) diarrhea, (-) constipation, (-) change in bowel habits
• GUT:(-) dysuria, (-) hematuria, (-) incontinence, (-) urinary frequency
• Musculoskeletal:(-) muscle pains, (-) joint pains, (-) weakness, (-) backache
• Hematological:(-) anemia, (-) excessive bleeding, (-) easy bruising
• Endocrine: (-) heat/cold intolerance, (-) weight change, (-) excessive sweating, (-) polydipsia, (-) polyphagia,
(-) polyuria
• Nervous system: (-) syncope, (-) left or right sided weakness
 Physical Examination
• General Survey: awake, conscious and coherent, nonambulatory, not in respiratory distress
• Height: 158 cm Weight: 68.5 kg BMI: 27.4 (Obese I)
• Vital Signs: 130/80 ; 74 bpm ; 22 cpm ; Temp: 36. 4 deg. Celsius ; SaO2: 98%
• Skin: no pallor, jaundice, cyanosis, rashes
• HEENT: atraumatic, (+) Chvostek’s sign, anicteric sclerae, pink palpebral conjunctivae, no ear
discharges, no NVE, (+) ~ 8cm transverse incisional scar at anterior neck, no CLAD, no neck
mass, no trismus
• Chest/Lungs: SCWE, no retractions, resonant on both lung fields, clear breath sounds
• Heart: Adynamic precordium, PMI at 5th ICS LMCL, good S1 and S2, no murmurs, thrilles and
heaves
• Abdomen: flabby, (+) ~4cm transverse incisional scar at RLQ , no spider angioma, no caput
medusae, NABS, tympanitic, no fluid wave, soft, no tenderness, no masses
• Extremities: no lesions, no edema, (+) carpopedal spasm, (+) Trosseau’s sign, CRT: < 2 secs
 Physical Examination
• Neurologic:
• GCS 15/15 (E4 V5 M6)
• Cerebrum: conscious, oriented to 3 spheres
• Cerebellum: no nystagmus
• Cranial Nerves:
• I: able to smell
• II: intact sense of sight
• III, IV, VI: pupils 2-3mm in size both equally round and reactive to light, intact EOMs, no
preferential gaze
• V: facial sensory functioning intact, intact muscles of mastication
• VII: symmetrical facial movements
• VIII: intact sense of hearing
• IX, X: uvula in midline, no deviation
• XI: able to turn head from left to right, able to raise and shrug shoulders
• XII: midline protrusion of the tongueno deviation
• Motor: 5/5 in all extremities
• Sensory: 100% in all extremeties
• Reflexes: Hyperreflexia in all extremities
 Laboratory Exams
Date Tests Name Result Unit Reference
Chemistry Section Range
09/12/2018 Sodium 145.00 mmol/L 136 – 150
Potassium 3.94 mmol/L 3.4 - 5.3
Ionized calcium 0.88 mmol/L 1.00 – 1.20
Phosphorus 1.70 mmol/L 0.86 – 1.44
Magnesium 0.90 mmol/L 0.70-1.05
Blood urea nitrogen 3.20 mmol/L 1.7 – 8.3
Creatinine 60.00 umol/L 44.2 – 150.3
 CBC Result Unit Reference Range
Hemoglobin L 119.00 g/L 123 – 153
Hematocrit 0.39 0.35 – 0.44
Red Blood Cell L 4.47 10^12/L 4.5 – 5.1
MVC 86.10 fL 80 – 100
MCH L 26.60 g/dL 27 – 32
MCHC L 30.90 g/dL 31 – 35
RDW 15.50 % 12 – 16
White Blood Cell 6.53 10^9/L 4.50 – 11.00
Differential Count
Segmenters 0.52 0.50 – 0.70
Lymphocytes 0.35 0.20 – 0.40
Monocytes 0.08 0.02 – 0.08
Eosinophil 0.04 0.01 – 0.04
Basophil 0.01 0.00 – 0.01
Platelet count 401.00 10^9/L 150 - 450
X-RAY
HEART & LUNGS (1 VIEW) ADULT

REPORT
Film is taken in poor inspiratory effort
Lungs are clear
Heart is magnified, hence, cannot be properly assessed.
Aorta is not dilated.
Diaphragm and sulci are intact.
The rest of the visualized chest structures are unremarkable.

IMPRESSION: NO SIGNIFICANT PULMONARY FINDINGS

 Admitting Diagnosis

Hypocalcemia secondary,
S/P total thyroidectomy (5/2018)
 In-Patient Management

• Calcium gluconate 10% in 10 ml SIVP (5-15 mins) at ER

• Calcium gluconate drip: 10 ampules + 1 L PNSS for 24 hours
revised to 2 ampules in 500 cc D5W for 12 hours for 3
cycles
• Calcium 600mg + VitD3 1000 IU tab, 2 tabs TID
• Calcitriol 0.3mg/tab 1 tab BID
• Levothyroxine 125 mg MWF; 112.5 mg TThSS
• Telmisartan 40 mg 1 tab OD
 Serum albumin and
Repeat Serum iCa

09/13/2018 ALBUMIN 40.18 g/L 38 - 50

IONIZED CALCIUM 0.99 mmol/L 1.00 – 1.20
 Final Diagnosis

S/P Total Thyroidectomy (5/2018)

Hypothyroidism secondary,
Hypocalcemia secondary, resolved
 Final Diagnosis

Postoperative Hypoparathyroidism,
Hypocalcemia secondary, resolved
S/P Total Thyroidectomy (5/2018)
Hypertension Stage II, controlled
 Discharge Medications

• Calcium 600mg + VitD3 1000 IU tab, 2 tabs TID

• Calcitriol 0.3mg/tab 1 tab BID
• Levothyroxine 125 mg MWF; 112.5 mg TThSS
• Telmisartan 40 mg 1 tab OD
 Hypocalcemia
• Corrected serum total calcium level <2.12 mmol/L or <8.5 mg/dL or
Let’s do it!
• Serum ionized
Patient A has a Ca
total< serum
1.0 mmol/L
calcium of 2.05 mmol/L with an albumin of
35 g/L. What is the corrected serum calcium?
• NORMAL
Answer:
Corrected total serum calcium 2.10-2.60 mmol/L or 8.5-10.2 mg/dl
Corrected serum total Ca = 2.05 mmol/L + [(40 – 35 g/L) x 0.02)]
Ionized Calcium 1.1-1.35 mmol/L or 4.4-5.4
= 2.05 mmol/L mg/dL
+ (5g/L x 0.02)
= 2.05 mmol/L + 0.10 mmol/L
• Cardiovascular and neuromuscular manifestations occur at
= or
<2.5 mg/dL 2.15
0.62mmol/L
mmmol/L

Corrected serum calcium = total serum calcium mmol/L + [(40 - serum albumin g/L) x 0.02)]
OR
Corrected serum calcium = total serum calcium mg/dL + 0.8 (4 - serum albumin g/L)
 Approach to Hypocalcemia

Cooper, M. & Gittoes, N.J.. 2008. Diagnosis and management of hypocalcemia. British medical journal. Vol 336: 1301.
Singla, S. et al.2006. Approach to a case of hypocalcemia. Journal, indian academy of clinical medicine.
7(4): 297.
Etiology of Hypocalcemia
Etiology of Hypocalcemia
Calcium Homeostasis and the Role of
Parathyroid Hormone
Pathophysiologic Effects of Hypocalcemia
Low Serum Calcium

Increase neuronal
permeability of Na+

Decreased
threshold potential

Hyperexcitability
state

Neuromuscular Effects Cardiovascular Effects:

Paresthesia to Tetany: Decreased cardiac
Muscle spasms contractility (heart failure)
Carpopedal spasms Arrythmia (prolonged
Trosseau’s sign QT/AV blocks)
Laryngeal spasms Ventricular fibrillation
Convulsions
Hyperreflexia
 Tetanic Signs

• Chvostek’s sign • Carpopedal spasm

• Trosseau’s sign
Post-operative Hypoparathyroidism

Occur after total thyroidectomy or removal of parathyroid hormone

Transient hypoparathyroidism Permanent hypoparathyroidism

<6 months >6 months
(frequency of 6.9% and 49%) (frequency of 0.4% and 33%)
 Management of Hypocalcemia
CHRONIC or ASYMPTOMATIC ACUTE SYMPTOMATIC

1. Elemental calcium 1000-1500 1. Calcium gluconate 10% in 10 ml + 50

mg/day in divided doses ml (D5W or PNSS) IV for 5-10 mins
+ 2. For continuing hypocalcemia,
Calcium gluconate 10 ampules + 1 L
1. Either Vitamin D2 or D3 25,000 – (D5W or PNSS) x 24 hours
100,000 U/daily or
2. Calcitriol 0.25 – 2.0 ug/day

LONG-TERM GOAL: maintain serum SHORT-TERM GOAL: control of symptoms

calcium in low normal range and avoid while minimizing complications
hypercalciuria

MONITORING:
One week after discharge until target serum calcium is achived then 3 months to 6 months
 THANK YOU

References:
1. Harrison’s Principles of Internal Medicine 19th Ed.
2. Guyton and Hall Medical Physiology 12th Ed.
3. Schwartz’s Principles of Surgery 10th Ed.
4. Singla, S. et al.2006. Approach to a case of hypocalcemia. Journal, indian academy of
clinical medicine. 7(4): 297.
5. Cooper, M. & Gittoes, N.J.. 2008. Diagnosis and management of hypocalcemia. British
medical journal. Vol 336: 1301.
6. Khan, M. et.al. 2011. Medical management of postsurgical hypothyroidism. Endocrine
practice. Vol. 17 (Supp 1). 18-25.
7. Kakava, K. et. al. 2016. Postsurgical hypoparathyroidism: a systematic review. In vivo.
30: 171-180
8. Turner, J. et. al. 2016. Emergency management of acute hypocalcemia in adult
patients. Society for endocrinology emergency guidance. 5-G7.
9. Schafer, A.L. 2016. Hypocalcemia: diagnosis and treatment. Endotext [Internet]. South
Dartmount (MA): MDText.com, Inc.