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Medical Series: Endocrine Part 2 : Parathyroid Dr. Acute Medicineman Trust Grade DoctorSocial MediasAims and Objectives • Parathyroid • Vitamin D • Calcium • Hypercalcaemia • HypocalcaemiaQuestion 1 th You’re a 5 year medical student. You’ve been asked to see a patient follow surgery for her parathyroid gland. The surgical consultant ask you, ‘what’s the role of parathyroid hormone?’ 3- A. ↑ serum Ca and ↓ PO 4 3- B. ↑ serum Ca and ↑ PO 4 C. ↓ serum Ca and ↑ PO 3- 4 D. ↓ serum Ca and ↓ PO 3- 4 E. Don’t knowAnswer 1 What’s the role of parathyroid hormone? A. ↑ serum Ca and ↓ PO 3- - PTH increases serum calcium and increase phosphate excretion. 4 2+ 3- B. ↑ serum Ca and ↑ PO 4 C. ↓ serum Ca and ↑ PO 3- 4 D. ↓ serum Ca and ↓ PO 43- E. Don’t knowParathyroid Hormone • 4x Parathyroid gland. • Posterior to thyroid gland. • Responds to serum Ca levels via Calcium sensitive receptors (CaSR). 3- • Also responds to serum PO . 4 3- • PTH release = ↑ serum Ca and ↓ PO 4 • PTH tightly controls Ca levels. • PTH also affects Vitamin D levels.Question 2 th You’re a 5 year medical student. You’re seeing a 75-year-old lady with significant renal impairment with the consultant. They’ve been started on adcal. The consultant asks you ‘what’s the role of vitamin D?’ A. ↑ serum Ca and ↓ PO 4- 3- B. ↑ serum Ca and ↑ PO 4 3- C. ↓ serum Ca and ↑ PO 4 D. ↓ serum Ca and ↓ PO 3- 4 E. Don’t knowAnswer 2 What’s the role of Vitamin D? A. ↑ serum Ca and ↓ PO 3- - Vitamin D also increases serum calcium and increases phosphate excretion. 2+ 3- B. ↑ serum Ca and ↑ PO 4 C. ↓ serum Ca and ↑ PO 3- 4 D. ↓ serum Ca and ↓ PO 43- E. Don’t knowQuestion 2b th You’re a 5 year medical student. You're seeing a 75-year-old lady with significant renal impairment with the consultant. They’ve been started on adcal. Which form of vitamin D is physiologically active? A. Cholecalciferol B. Ergocalciferol C. Calcitriol D. 25-Hydroxycholecalciferol E. Don’t knowAnswer 2b Which form of vitamin D is physiologically active? A. Cholecalciferol B. Ergocalciferol C. Calcitriol D. 25-Hydroxycholecalciferol E. Don’t knowQuestion 2c th You’re a 5 year medical student. You're seeing a 75-year-old lady with significant renal impairment with the consultant. They’ve been started on adcal. Which organ is in control of the final step of calcitriol synthesis? A. Skin B. Parathyroid C. Kidneys D. Liver E. Don’t knowAnswer 2c Which organ is in control of the final step of calcitriol synthesis? A. Skin B. Parathyroid C. Kidneys D. Liver E. Don’t knowVitamin D • Vitamin D is a hormone. • Production = Oral or UVB (sunlight). • Has to be metabolized to its active form. • Active Vit D= ↑ serum Ca and ↓ PO 3- 4 • Calcitriol is the active form of vitamin D. • It has a short half-life of a few minutes. Renally ProducedQuestion 3 th You’re a 5 year medical student on placement in the endocrinology clinic. A 42-year-old patient is being monitored for her thyroid cancer. The consultant explains that she has high levels of calcitonin because of the cancer. What type of thyroid cancer does she have? A. Papillary B. Follicular C. Medullary D. Anaplastic E. Don’t knowAnswer 3 What type of thyroid cancer does she have? A. Papillary Good prognosis B. Follicular Good prognosis C. Medullary Bad prognosis. Arises from the C-Cell of the thyroid gland that produce calcitonin. D. Anaplastic Worst prognosis E. Don’t knowCalcitonin 3- • ↓ serum Ca and ↓ PO 4 • Thyroid C-Cells = calcitonin • decreased osteoclast activity. • Increased Bone phosphate. • Calcitonin may also decrease renal resorption of calcium. • Medullary thyroid = C-Cells • low calcitonin is not known to have adverse affects. • Having high levels does not cause hypercalcaemia either. • Diagnostic significanceQuestion 4 th You’re a 5 year medical student on placement in the ICU. A 52-year-old patient is being monitored for severe hypercalcaemia secondary to Milk-Alkali Sydnrome. The consultant ask you, ‘What state is the majority of serum calcium in within the blood in a heathy person?’ A. Phosphate bound B. Albumin bound C. Free (AKA Ionised) D. Citrate bound E. Don’t knowAnswer 4 ‘What state is the majority of serum calcium in within the blood?’ A. Phosphate bound Small amount is phosphate bound. B. Albumin bound Large amount is albumin bound but majority is free. C. Free (AKA Ionised) In a normal patient the majority of calcium is free. D. Citrate bound Can be citrate bound, more significant in haemodialysis patients. E. Don’t know 10% Other Albumin- 40% Ca2+ Proportions affected by: • pH • Serum albumin level • Prescence of other chelators 50% Free Ca2+Calcium Transport • A majority of calcium is free. • But a lot of it is also albumin bound, as a lot of things are… • About 50% is free and 40% is bound (AKA ionised). • A minority of calcium is bound to other chelators, such as phosphate. • This can be important in hyperphosphataemic states, such as CKD where there is low vitamin D and more phosphate binds to calcium.Question 5 The consultant also asks you, ‘In what state is calcium physiologically active?’ A. Phosphate bound B. Albumin bound C. Free (AKA Ionised) D. Citrate bound E. Don’t knowAnswer 5 ‘What state is the majority of serum calcium in within the blood?’ A. Phosphate bound Small amount is phosphate bound. B. Albumin bound Large amount is albumin bound, but this is not physiologically active. C. Free (AKA Ionised) Whilst the majority is free it is also the physiologically active calcium. D. Citrate bound Can be citrate bound, more significant in haemodialysis patients. E. Don’t knowFree Calcium & Adjusted Calcium Physiologically active calcium = free (AKA ionised) This is the calcium that can enter tissues and react with things. Adjusted Ca2+ = surrogate marker. Adjusted Ca2+ corrects calcium level if you had a normal albumin. blood gas = ionised calcium. But it is easier to do repeat bloods instead of blood gasses (unless they have an art line!).Question 6a A 45-year-old lady had a total thyroidectomy for follicular thyroid cancer. Following surgery you and an F2 are asked to review her in the night, as she is feeling unwell. You note that as a blood pressure is being taken, her wrist flexes and fingers extend. She has had blood tests. The F2 asks, ‘how you would treat this complication?’ A. IV calcium gluconate B. IV calcium chloride C. Oral calcium D. IV Magnesium Sulphate E. Don’t knowAnswer 6a ‘How you would treat this complication?’ A. IV calcium gluconate Symptomatic hypocalcaemia secondary to thyroid surgery. B. gluconate. chloride Another option but contains 3x as calcium compared to calcium C. Oral calcium Not rapid acting enough, intravenous replacement is required. D. IV Magnesium Sulphate Will need to check magnesium, however there was no indication/reason for it to be low. E. Don’t knowQuestion 6b A 45-year-old lady had a total thyroidectomy for follicular thyroid cancer. Following surgery you and an F2 are asked to review her in the night, as she is feeling unwell. You note that as a blood pressure is being taken, her wrist flexes and fingers extend. She has had blood tests. What sign has been elicited?’ A. Chvostek’s B. Trousseau’s C. Babinski’s D. Kernig’s E. Don’t knowAnswer 6b What sign has been elicited? A. Chvostek’s Tapping of the facial nerve over the parotid gland causes twitching. B. Trousseau’s Inflation of pressure cuff f -or ins, causes wrist flexion and finger extension. C. Babinski’s Upgoing plantars, sign of upper motor neurone lesion. D. Kernig’s Sign of meningism, bending of hip and knee, then extending knee. E. Don’t knowQuestion 6c Which sign if more specific and sensitive to for hypocalcaemia? A. Chvostek’s B. Trousseau’sAnswer 6c What sign has been elicited? A. Chvostek’s Also seen in hypomagnesaemia and metabolic alkalosis. B. Trousseau’s More sensitive and specific.Hypocalcaemia- Aetiology (Hypo) Hypovitamin Dism Hyporenalism Hypoparathyroidism- 1. Injury 2. Autoimmune 3. Infiltration Hypoalbuminism Hypomagnasaemia Bisphonates Pseudohypoparathyroidism- Resistance to PTH hormone HyperphosphataemiaHypocalcaemia- Clinical Features (SPASMODIC) Spasm Perioral paraesthesia Anxiety Seizure Muscle tone increase Orientation impaired Dermatitis Impetigo herpetiformis (pustular psoriasis) Chvostek’s, Cardiomyopathy, CataractsHypocalcaemia- Management Rx/ Oral OR IV calcium, also consider replacing vitamin D if low, consider phosphate binder in CKD patients, and definitely replace magnesium if low. IV Calcium = Ca gluconate or Ca Chloride Ca Chloride 3x more Ca and give through large vein as irritatingQuestion 7 What other electrolyte abnormality can calcium be helpful in treating? A. Hypokalaemia B. Hyperkalaemia C. Hypernatraemia D. Hypophosphataemia E. Don’t knowAnswer 7 What other electrolyte abnormality can calcium be helpful in treating? A. Hypokalaemia B. Hyperkalaemia Used a cardiac membrane stabiliser C. Hypernatraemia D. Hypophosphataemia E. Don’t knowHyperkalaemia • Increased potassium = RMP and therefore more likely to hit cardiac myocyte action potential threshold. Calcium makes the the RMP less negative to restore the difference between the RMP and AP threshold in the setting of hyperkalaemia. • Calcium gluconate 10% in 10mls • Or Calcium Chloride 10% in 10mls (contains 3x more calcium!). • This is to protect against arrhythmia, the potassium then needs to be shifted intracellularly and then either urinated or dialysed out.Question 8 A 60-year-old lady presents with abdominal pain, excessive urination, pains and aches over her body. Her bloods are shown in the table. The consultant ask you ‘what test should we request next’? A. CT-Scan B. Protein electrophoresis C. PTH D. Blood Gas E. Don’t knowAnswer 8 ‘What test should we request next’? A. CT-Scan- Second most common cause is malignancy and would, therefore consider this if other causes excluded. B. Protein electrophoresis- If suspecting multiple myeloma (CRAB) to look for monoclonal antibodies. C. PTH – The most common cause of hypercalcaemia is hyperparathyroidism. D. Blood Gas- Won’t be as helpful at this moment diagnostically, but can be easily done. E. Don’t knowHypercalcaemia-Aetiology 1. Hyperparathyroidism 2. Malignancy Other. Sarcoidosis, MM, Milk-Alkali Syndrome, thyrotoxicosis, dehydration & Vitamin D toxicityHypercalcaemia-Clinical Features Renal Stones Pissing thrones Painful bones Abdominal moans (constipation) Listless groans psychiatric overtonesHypercalcaemia-Management Fluids Consider bisphosphonates Treat underlying cause if possiblePrimary Hyperparathyroidism Increased PTH = Increased Ca2+ 1. Adenoma 2. Multiglandular 3. Familial causes e.g. MEN 4. Carcinoma 5. CaSR issues e.g. Familial hypocalciurichypercalcaemia 6. PTHrpSecondary Hyperparathyroidism Physiologic response to low calcium Low calcium = increased PTH Vitamin D and CKD Chronic secondary = excessive PTH = hypercalcaemia = tertiary O O F Feedback & Instagram + 3C N O Please complete feedback to receive slides and cheat sheet!Follow our In3tagram p ge for MCQs NH O Cl CH 3 CH3 OH CH 3 CH OH 3 3HC CH3 3HC O