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| gray
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can barely read posts.
usually I google for the answers
this is what i found.
Hypocalcaemia
In hospital practice, hypocalcaemia is most commonly seen in subjects with dietary vitamin D deficiency or as a transient event after total thyroidectomy. Hypoparathyroidism is most commonly due to surgical removal but may also be caused by autoimmunity, infiltration by amyloid or heavy metals eg iron in haemochromatosis or thalassaemia, or copper in Wilson's disease.
Hypocalcaemia can occur in acute pancreatitis, largely as a result of the release of pancreatic lipase into retroperitoneal space and peritoneal cavity, where it saponifies, releasing free fatty acids which bind calcium. Hypocalaemia in pancreatitis is associated with a poor prognosis. The fall in calcium is usually gradual and investigation for the cause should be delayed until the pancreatitis has settled. This is to ensure that any changes in PTH are not secondary to the plasma calcium. Treatment for hypocalcaemia is probably only necessary if symptoms eg cramps or parasthesiae occur. The mechanisms for hypocalcaemia in endotoxic shock are currently unknown.
Hyperventilation causes an acute respiratory alkalosis and this affects calcium binding to circulating proteins. The result is tetany with normal total but reduced ionised calcium since the calcium has no competition for protein binding sites and is functionally removed. The hyperventilation may be due to hysteria, head injury etc.
Abnormally low plasma concentrations of magnesium, phosphate and potassium are frequently (20-30%) detected in association with hypocalcaemia and these abnormalities should be corrected; as they may be the primary cause or, at least, an exacerbating factor of the hypocalcaemia due to their effects on renal tubular function and, in the case of magnesium, on the inhibition of PTH synthesis and secretion.
Reference
* Bushinsky DA, Monk RD. Calcium. Lancet 1998;352:306-311.
So I would have to go for hypomg.
Is the positive blood in stool significant.
Q for you.
Is a person who dies in ED a med examiners case.
can the family refuse an autopsy.
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| sandra
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@gray.
to read post, click on image..once the image opens, click on it once more to magnify
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| sandra
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for the last q, im really confused...hypomagnesemia causes hypocalcemia by causing end organ resustance to PTH. so is it B or E?
and again, in cirrhosis, vitd def can lead to hypocalcemia..so is it defection hydroxylation of vit d? any one?
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| dr9576
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| Miradautas Vras
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Am I the only one who noticed that ALL these questions are verbatim from UW??? I mean NBME and UW are same or what!
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| macintosh
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20. A 9-year-old boy is brought to the physician because of a 4-day history of pain in a tooth. He has had shaking chills during the past 2 days. Although he points to a tooth as the source of the pain, his dental examination 2 days ago showed no abnormalities. Ibuprofen relieves his pain for a short time. He has no history of serious illness. Growth and development are appropriate for age. He is in severe distress. His temperature is 39°C (102.2T), pulse is 120/min, and blood pressure is 90/60 mm Hg.The right side of the face, including the area around the right periorbital tissue, is edematous and mildly erythematous. On percussion of the upper jaw inside the oral cavity, there is severe tenderness of the right upper jaw and the area under the right eye. Examination of the oral cavity shows no other abnormalities. Both tympanic membranes are clear. Which of the following is the most likely source of infection?
O A) Pharynx
OB) Right maxillary sinus
O C) Right middle ear
O D) Right periorbital region
O E) Right upper molar
B
24. A 70-year-old woman is hospitalized for evaluation of a single, transient episode of right-sided weakness. She has type 2 diabetes mellitus controlled with diet. Seven years ago, she underwent lumpectomy and radiation therapy for localized breast cancer and has had no evidence of recurrence. Examination shows a left carotid bruit. Arteriography shows 80%-90% stenosis of the left internal carotid artery in a segment just distal to where it branches from the common carotid artery. On admission, her serum glucose level is 310 mg/dL; after adequate hydration, her serum glucose level decreases to 180 mg/dL. Serum electrolyte levels are within normal limits. Which of the following is the most appropriate recommendation to prevent cerebral infarction in this patient?
O A) Daily aspirin therapy only
OB) Insulin therapy only
O C) Low-dose heparin therapy only
O D) Warfarin therapy only
O E) Endarterectomy and daily aspirin therapy
O F) Endarterectomy and low-dose heparin therapy
O G) Endarterectomy and warfarin therapy
E (I am not sure of the answer. Please provide your own answer with reasoning)
26. A 37-year-old man comes to the physician 2 days after the sudden onset of severe low back pain. The pain began when he was lifting heavy boxes. He is otherwise healthy and takes no medications. Examination shows paraspinal muscle tenderness and spasm. After 5 days of bed rest and oxycodone therapy, his back pain resolves. Which of the following measures is most likely to prevent a recurrence of his symptoms?
O A) Exercise program
O B) Use of a back brace
O C) Spinal manipulation
O D) Nonsteroidal anti-inflammatory drug therapy
O E) Use of muscle relaxants
A
44. A 62-year-old man with a 20-year history of alcoholism is admitted to the hospital for treatment of alcoholic hepatitis. He appears
disheveled and malnourished. He is 198 cm (6 ft 6 in) tall and weighs 70 kg (155 lb); BMI is 18 kg/m2. Examination shows jaundice and temporal wasting. Scattered rhonchi are heard throughout all lung fields. Cardiac examination shows no abnormalities. Bowel sounds are normal. The liver span is 16 cm. Sensation to pinprick and light touch is decreased over the feet. Deep tendon reflexes are decreased at the ankles. Laboratory studies show:
Hematocrit 33%
Platelet count 145,000/mm3
Serum
Na+ 131 mEq/L
Cl- 92 mEq/L
K+ 3.1 mEq/L
HC03" 26 mEq/L
Mg2+ 0.8 mEq/L
Ca2+ 5.8 mg/dL
Urea nitrogen (BUN) 6 mg/dL
Creatinine 0.8 mg/dL
Test of the stool for occult blood is positive. Which of the following is the most likely mechanism of this patient's hypocalcemia?
O A) Chronic metabolic acidosis
O B) Hypomagnesemia
O C) Impaired hydroxylation of vitamin D
O D) Primary hyperparathyroidism
O E) Renal resistance to parathyroid hormone
C (H/O decreased sensations and decreased DTR is not compatible with hypomagnesemia. Absorption of Vitamin D appears to be normal. However there is decreased 25-hydroxylation.)
Please discuss your choices with me.
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| kaphoury
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Rt maxillary sinus
endarterectomy and warfarin
use of back brace
hypomagnesia
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| wasedf
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Hi guys, I agree with Macintosh for all the questions except for the last one. This is my two cents on questions C and D. I checked them up on Up to date. And if we see C, it is asking for prevention of recurrences. It is interesting that exercise is not indicated in the acute phase, but is used for the prevention. Please find the sections from Up to Date below.
EXERCISE, PHYSICAL THERAPY, AND OTHER PHYSICAL MODALITIES Exercise …quot; There is no evidence to suggest that back exercises are effective for patients in acute pain, and some trials suggest that back exercises may even be counterproductive [14,45]. A 2005 systematic review of 11 studies in acute back pain showed no improvement in pain scores for exercise relative to control (pain score 0.03 points, 95% CI -1.3 to 1.4) [46]. Patients should be encouraged to walk and resume normal daily activities as quickly as possible, but exercises specifically targeting the back are not indicated. Once the acute phase has subsided, however, exercise may help prevent recurrences. Effective regimens typically combine aerobic exercise with exercises specifically aimed at improving strength and endurance of the lumbar musculature [46]. Exercise for chronic pain is discussed separately. (See "Rehabilitation program for the low back"). PREVENTION Ergonomic design of strenuous job tasks in the workplace is an intuitively attractive preventive measure. An entire industry has been built around this premise, despite little supporting evidence. Rigorous evaluations of such interventions are difficult, because of heterogeneity in job tasks, restrictions imposed by labor and management, regulatory requirements, the difficulty of blinding, among many other factors. However, there is at least modest evidence from a clinical trial in which entire companies were randomly allocated to intervention or control conditions, suggesting that ergonomic design of job tasks may facilitate return to work and reduce the chronic nature of pain [77]. Exercise intervention may have some value both in preventing first episodes of back pain and in preventing recurrences after patients have had back pain. The relatively few randomized trials are of low quality, but are consistent in suggesting a benefit for reducing the incidence or perception of back pain [63,78]. There appears to be little if any value to the use of corsets as a preventive measure [62]. There is no evidence that smoking cessation or weight loss in appropriate patients effectively prevents back pain episodes; however, there are multiple validated other health-related reasons to promote these goals [79].
About question d, my first hunch was to go with c, since a liver problem should mean impaired hydroxylation of vitamin D. However, if we read carefully, there is no mention of cirrhosis or any stigmata of cirrhosis. The patient is a chronic alcoholic and has hypomagnesemia. The hepatic changes mentioned could go along with alcoholic hepatitis. The question gives many clues to the poor nutrition status of the pat. Low BMI, temporal wasting etc.
These are the sections from uptodate. Alcohol …quot; Hypomagnesemia is common in alcoholic patients admitted to the hospital; in one study, for example, the prevalence was 30 percent [14]. Excessive urinary excretion of magnesium occurred in 18 of the 38 patients with hypomagnesemia. The defect in urinary excretion appears to reflect alcohol-induced tubular dysfunction that is reversible within four weeks of abstinence [15]. This effect is relatively modest and other factors are also thought to contribute to hypomagnesemia in these patients, including dietary deficiency, acute pancreatitis, and diarrhea. Disorders of magnesium metabolism …quot; Magnesium depletion causes hypocalcemia through several different mechanisms. One is PTH resistance, which occurs when serum magnesium concentrations fall below 0.8 meq/L (1 mg/dL or 0.4 mmol/L). The second is decreased PTH secretion, which occurs in patients with more severe hypomagnesemia. Malabsorption, chronic alcoholism, and cisplatin therapy are the most common causes of hypomagnesemia; others include prolonged parenteral fluid administration, diuretic therapy, and the administration of aminoglycosides. (See "Causes of hypomagnesemia"). Despite PTH resistance or PTH deficiency, most patients with hypomagnesemia have normal or low serum phosphate concentrations, probably because of poor intake. The hypocalcemia cannot be corrected with calcium; the patients must be given magnesium. Although magnesium depletion is typically suspected from the presence of hypomagnesemia, a few patients with magnesium-responsive hypocalcemia but normal serum magnesium concentrations have been described. (See "Signs and symptoms of magnesium depletion", section on Normomagnesemic magnesium depletion). Severe hypermagnesemia, a very rare disorder, also can cause hypocalcemia, by suppressing the secretion of PTH [17]. This requires a serum magnesium concentration above 5 meq/L (6 mg/dL or 2.5 mmol/L), a concentration encountered only when magnesium is given to women with eclampsia. Symptomatic hypocalcemia is rare in these patients, most likely due to its short duration and the antagonistic neuromuscular effects of hypermagnesemia. (See "Causes and treatment of hypermagnesemia").
My only fear is that these questions do need quite a lot of thinking, doing it in a short time remains the challenge!!!
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