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  #1  
Old 10-30-2011
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Arrow hypocalcemia

A nurse calls you to ask about a low calcium level. She is concerned about one of the patients on your service, a 48-year-old alcoholic man admitted after being found stuporous in the park. The patientís mental status has improved with restarting his lactulose and discharge is planned for tomorrow. His temperature is 37.0 C (98.6 F), blood pressure is 148/80 mm Hg, pulse is 62/min, and respirations are 20/min. The patient is alert and oriented and does not seem to be in any distress. Examination reveals temporal wasting, numerous chest wall spider angiomas, mild gynecomastia, and marked hepatosplenomegaly. The physical findings of shifting dullness and 2+ pitting edema bilaterally are also present. The nurse is concerned because the patientís total calcium level is 7.0 mg/dL, and she wants to know what to do. Which of the following is the most appropriate management at this time?
A. Administer calcium carbonate, 1-2 g/day
B. Administer calcium gluconate, 200 mg (2 ampules) stat
C. Administer vitamin D supplementation
D. Check albumin level
E. Check magnesium level
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  #2  
Old 10-30-2011
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HOW ABOUT D?
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  #3  
Old 10-31-2011
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check albumin level. liver disease hypoalbuminemia.ionized ca levels may be normal.
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Old 10-31-2011
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The correct answer is D. This patientís hypocalcemia is likely factitious. Given the obvious advanced liver disease, a quick review of this patientís recent liver function tests will likely reveal a low albumin. Calcium in the bloodstream exists as bound (mainly to albumin) and free (or ionized) calcium, the latter of which is physiologically important. As albumin levels decrease, common in advanced liver disease, total calcium also decreases; however ionized calcium levels remain constant. An ionized calcium level can be checked or a simple adjustment for the reduced albumin can be made. For every 1-g reduction in albumin below 4 g/L (normal), total calcium levels will decrease 0.8 mg/dL. For example, if this patientís albumin were 2 g/L (a reasonable guess), the calcium level would be 1.6 mg/dL lower than if the albumin were normal. The adjusted calcium level would be 8.6 (7.0 + adjustment of 1.6), which is within the normal range and does not require treatment.

Calcium carbonate (choice A), often combined with vitamin D (choice C), is good strategy for calcium supplementation in patients with chronic low calcium or those who are at risk for osteoporosis. Neither is indicated in this patient.

Calcium gluconate (choice B) is a good choice for acute hypocalcemia because it can be given intravenously and is readily available (being kept, among other places, on most crash carts).

Magnesium levels (choice E) should be checked in cases of persistent hypocalcemia or hypokalemia. Magnesium is believed to play a role in the transmembrane pumps that regulate ion absorption.
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  #5  
Old 11-01-2011
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I would still go for Magnesium level coz decreased albumin will increase not decrease the total calcium but will not effect ionized calcium where as he is alcholic so his magnesium levels will be down which explains his hypocalcemia if i am wrong plz correct me any1 of you............
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  #6  
Old 11-01-2011
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decreased albumin levels decrease calcium levels.....here there are no signs of hypocalcemia as the level of ca is appropriate to decresed albumin levels which we can expect in an alcoholic
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