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| {{DiseaseDisorder infobox | | | __NOTOC__ |
| Name = Hypocalcemia |
| | {{Hypocalcemia}} |
| ICD10 = {{ICD10|E|83|5|e|70}} |
| | {{CMG}}; {{AE}} {{VKG}}{{Vbe}} |
| ICD9 = {{ICD9|275.41}} |
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| ICDO = |
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| Image = Ca-TableImage.png |
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| Caption = [[Calcium]] |
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| OMIM = |
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| OMIM_mult = |
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| MedlinePlus = |
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| eMedicineSubj = emerg |
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| eMedicineTopic = 271 |
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| DiseasesDB = 6412 |
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| MeshID = D006996 |
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| }} | |
| {{SI}} | |
| {{CMG}} | |
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| {{Editor Help}} | | {{SK}} hypocalcemia; low serum calcium level; hypocalcaemia |
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| ==Overview==
| | {| class="infobox" style="float: right;" |
| | | | style="vertical-align: middle; padding: 5px;" align=center | [[File:Siren.gif|30px|link=Hypocalcemia resident survival guide]] |
| '''Hypocalcemia''' is the presence of low [[blood plasma|serum]] [[calcium]] levels in the [[blood]], usually taken as less than 3.5 mmol/L or 8.8 mg/dl or an [[ion]]ized calcium level of less than 1.1 mmol/L (4.5 mg/dL). It is a type of [[electrolyte disturbance]]. In the blood, about half of all calcium is bound to proteins such as [[serum albumin]], but it is the unbound, or ''ionized'', calcium that the body regulates. If a person has abnormal levels of blood proteins then the plasma calcium may be inaccurate. The ionized calcium level is considered more clinically accurate in this case.
| | | style="vertical-align: middle; padding: 5px;" align=center | [[Hypocalcemia resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
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| [[Calcium]] is the most abundant mineral in the body. 99% of the body's calcium is stored in bone. Calcium is found in plasma and is either protein-bound or ionized and readily available.
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| ==Alkalosis==
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| As [[blood plasma]] hydrogen ion concentration decreases, caused by respiratory or metabolic [[alkalosis]], freely ionized calcium concentration decreases. This freely ionized calcium is the biologically active component of blood calcium. Since a portion of both hydrogen ions and calcium are bound to serum [[albumin]], when blood becomes alkalotic, bound hydrogen ions dissociate from albumin, freeing up the albumin to bind with more calcium and thereby decreasing the freely ionized portion of total serum calcium. For every 0.1 increase in pH, ionized calcium decreases by about 0.05 mmol/l.
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| This hypocalcemia related to alkalosis is partially responsible for the cerebral [[vasoconstriction]] that causes the [[lightheadedness]], [[fainting]], and [[parasthesia]] often seen with [[hyperventilation]].
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| ==Causes==
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| ===Complete Differential Diagnosis of the Causes of Hypocalcemia===
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| (In alphabetical order)
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| * Absent active [[vitamin D]]
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| * Absent [[parathyroid hormone]] (PTH)
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| * Acquired [[hypoparathyroidism]]
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| * [[Acute pancreatitis]]
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| * [[Acute renal failure]]
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| * [[Adrenocortical hyperplasia]]
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| * [[Alcohol abuse]]
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| * [[Alkalosis]]
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| * [[Anticonvulsant]] therapy
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| * [[Anticonvulsant]]s
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| * [[Breast cancer]]
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| * [[Bronchial cancer]]
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| * [[Burns]]
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| * [[Chelation]] therapy
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| * [[Chronic renal failure]]
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| * [[Cirrhosis]]
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| * Decreased dietary intake
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| * Decreased [[ultraviolet]]/sun ([[vitamin D deficiency]])
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| *Defective [[Vitamin D]] metabolism
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| * Deficient [[PTH]]
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| * [[DiGeorge's Syndrome]]
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| * [[Diuretic]] therapy
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| * [[Drugs]]
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| * [[Eating disorders]]
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| * [[Enemas]], [[laxative]]s
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| * Enhanced [[bone]] formation
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| * Excessive secretion of calcitonin
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| * Exposure to [[hydrofluoric acid]]
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| * [[Familial hypocalcemia]]
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| * Following [[thyroidectomy]]
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| * Hereditary [[hypoparathyroidism]]
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| * "Hungry Bone Syndrome" following [[parathyroidectomy]],
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| * [[Hyperphosphatemia]]
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| * [[Hyperventilation]].
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| * [[Hypoalbuminemia]] (pseudohypocalcemia)
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| * [[Hypomagnesemia]]
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| * [[Hypoparathyroidism]]
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| * [[Hypoproteinemia]]
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| * Increased diuresis with physiologic saline solution
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| * Ineffective active [[vitamin D]]
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| * Ineffective [[PTH]]
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| * Intestinal [[malabsorption]]
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| * Intravenous phosphate administration
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| * Kidney diseases with reduced formation of activated [[vitamin D]]
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| * [[Magnesium]] depletion
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| * [[Magnesium]] over supplementation
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| * [[Malabsorption]]
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| * Mal[[digestion]]
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| * [[Medullary carcinoma of the thyroid]]
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| * Neonatal tetany
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| * [[Nephrotic Syndrome]]
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| * [[Osteitis fibrosa]] following [[parathyroidectomy]]
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| * Osteoblastic metastases
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| * [[Osteoporosis]]
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| * [[Pancreatitis]]
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| * Polyglandular [[autoimmune]] syndrome
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| * Postoperative
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| * Prolonged use of medications/laxatives containing [[magnesium]]
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| * [[Pseudohypoparathyroidism]]
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| * [[Renal Failure]]
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| * [[Rhabdomyolysis]]
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| * [[Rickets]]
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| * [[Sepsis]]
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| * [[Septic shock]]
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| * Severe acute [[hyperphosphatemia]]
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| * [[Short bowel syndrome]]
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| * [[Steroid]] therapy
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| * [[Thyroid cancer]]
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| * [[Transfusion]] of citrated blood
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| * [[Tumor lysis syndrome]]
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| * [[Vitamin D deficiency]]
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| * Vitamin-D dependent [[rickets]], type I
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| ===Complete Differential Diagnosis of the Causes of Hypocalcemia===
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| (By organ system)
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| {|style="width:80%; height:100px" border="1"
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| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular''' | |
| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | No underlying causes
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| |- | |
| |-bgcolor="LightSteelBlue"
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| | '''Chemical / poisoning''' | |
| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Dermatologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Drug Side Effect''' | |
| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Ear Nose Throat'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Endocrine'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Environmental'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Gastroenterologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Genetic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Hematologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Iatrogenic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Infectious Disease'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Musculoskeletal / Ortho'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Neurologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Nutritional / Metabolic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Obstetric/Gynecologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Oncologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Opthalmologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Overdose / Toxicity'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Psychiatric'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Pulmonary'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Renal / Electrolyte'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Rheum / Immune / Allergy'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Sexual'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Trauma'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Urologic'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Miscellaneous'''
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| |bgcolor="Beige"| No underlying causes
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| |-
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| |} | | |} |
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| | ==[[Hypocalcemia overview|Overview]]== |
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| | ==[[Hypocalcemia historical perspective|Historical Perspective]]== |
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| | ==[[Hypocalcemia classification|Classification]]== |
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| | ==[[Hypocalcemia pathophysiology|Pathophysiology]]== |
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| == Diagnosis == | | ==[[Hypocalcemia causes|Causes]]== |
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| === History and Symptoms === | | ==[[Hypocalcemia differential diagnosis|Differentiating Hypocalcemia from other Diseases]]== |
| * [[Fatigue]]
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| * [[Weakness]]
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| * [[Muscle cramp]]ing and spasm
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| * [[Nausea]] and [[vomiting]]
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| * [[Abdominal pain]]
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| * [[Depression]]
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| * [[Irritability]]
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| * [[Delirium]]
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| * [[Psychosis]]
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| * [[Seizures]] (with severe hypocalcemia)
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| * [[Perioral]] tingling and [[parasthesia]], 'pins and needles' sensation over the extremities of hands and feet. This is the earliest symptom of hypocalcemia.
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| ==Signs== | | ==[[Hypocalcemia epidemiology and demographics|Epidemiology and Demographics]]== |
| * [[Tetany (medical sign)|Tetany]], carpopedal spasm are seen.
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| * Latent tetany
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| ** [[Trousseau sign of latent tetany]] (eliciting carpal spasm by inflating the [[blood pressure]] cuff and maintaining the cuff pressure above [[systolic]])
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| ** [[Chvostek's sign]] (tapping of the inferior portion of the [[zygoma]] will produce facial spasms)
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| * Tendon reflexes are hyperactive
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| * Life threatening complications
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| ** [[Laryngospasm]]
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| ** [[Cardiac arrhythmia]]s
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| ==Clinical Features Associated with Hypocalcemia== | | ==[[Hypocalcemia risk factors|Risk Factors]]== |
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| * [[Abdominal pain]]
| | ==[[Hypocalcemia screening|Screening]]== |
| * [[Alopecia]]
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| * [[Anxiety]]
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| * [[Atopic eczema]]
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| * [[Biliary colic]]
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| * [[Brittle nails]]
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| * [[Bronchial spasm]]
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| * Calcification of cerebral cortex or cerebellum
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| * [[Cardiomyopathy]]
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| * [[Choreoathetosis]]
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| * [[Chvostek's sign]]
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| * Coarse hair
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| * [[Confusion]]
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| * [[Congestive heart failure]]
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| * Delayed tooth eruption
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| * Disorientation
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| * [[Dry skin]]
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| * [[Dysphagia]]
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| * [[Dyspnea]]
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| * Dystonic spasms
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| * Enamel hypoplasia
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| * Exfoliative dermatitis
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| * Extrapyramidal signs due to calcification of basal ganglia
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| * [[Fatigue]]
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| * Impaired intellectual ability
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| * Impetigo herpetiformis
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| * Increased dental caries
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| * Increased intracranial pressure
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| * [[Irritability]]
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| * [[Laryngeal spasm]]
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| * [[Muscle cramp]]s
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| * Nonspecific EEG changes
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| * [[Papilledema]]
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| * [[Paresthesia]]
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| * [[Parkinsonism]]
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| * Personality disturbances
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| * [[Polymyositis]]
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| * Prolonged QT interval in EKG
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| * [[Psoriasis]]
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| * [[Psychoneurosis]]
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| * [[Psychosis]]
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| * [[Seizure]]s (focal, petit mal, grand mal)
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| * Shortened premolar roots
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| * Subcapsular cataracts
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| * [[Tetany]]
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| * Thickened lamina dura
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| * [[Trousseau's sign]]
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| * [[Wheezing]]
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| == Laboratory Findings == | | ==[[Hypocalcemia natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| Suggested initial laboratory studies include the following:
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| * Serum calcium
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| * Ionized calcium
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| * [[Complete blood count]]
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| * Blood urea nitrogen (BUN)/creatinine
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| * [[Magnesium]]
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| * [[Albumin]]
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| * [[Phosphorus]]
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| * Amylase/lipase
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| Additional laboratory studies to be obtained as part of a more complete evaluation include the following:
| | ==Diagnosis== |
| * [[Vitamin D]] levels
| | [[Hypocalcemia history and symptoms|History and Symptoms]] | [[Hypocalcemia physical examination|Physical Examination]] | [[Hypocalcemia laboratory findings|Laboratory Findings]] | [[Hypocalcemia electrocardiogram|Electrocardiogram]] | [[Hypocalcemia x ray|X Ray]] | [[Hypocalcemia CT|CT]] | [[Hypocalcemia MRI|MRI]] | [[Hypocalcemia echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Hypocalcemia other imaging findings|Other Imaging Findings]] | [[Hypocalcemia other diagnostic studies|Other Diagnostic Studies]] |
| * [[Parathyroid hormone]]
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| ==Electrocardiographic Findings== | | ==Treatment== |
| # Prolongation of the [[QTc interval]] is the major EKG finding
| | [[Hypocalcemia medical therapy|Medical Therapy]] | [[Hypocalcemia surgery|Surgery]] | [[Hypocalcemia primary prevention|Primary Prevention]] | [[Hypocalcemia secondary prevention|Secondary Prevention]] | [[Hypocalcemia cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Hypocalcemia future or investigational therapies|Future or Investigational Therapies]] |
| # There is a lengthening of the interval between the end of the [[QRS]] and the beginning of the [[T wave]] (i.e. [[ST-segment]] lengthening).
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| ==EKG examples== | | ==Case Studies== |
| [[image:Hypocalcemia_ProlongedQT.jpg|thumb|left|300px|Prolonged QTc interval due to hypocalcemia]] | | [[Hypocalcemia case study one|Case #1]] |
| <br clear="left"/>
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| ==Management== | | ==Related Chapters== |
| * Two [[ampoule]]s of [[intravenous]] [[calcium gluconate]] 10% is given slowly in a period of 10 minutes, or if the hypocalcemia is severe, [[calcium chloride]] is given instead. | | * [[Calcium metabolism|Calcium Metabolism]] |
| * Maintenance doses of both calcium and vitamin-D (often as 1,25-(OH)<sub>2</sub>-D<sub>3</sub>, i.e. [[calcitriol]])) are often necessary to prevent further decline. | | * [[Hypercalcaemia]] |
| | * [[Calcium deficiency (plant disorder)|Calcium Deficiency (Plant Disorder)]] |
| | * [[Hypomagnesemia with secondary hypocalcemia|Hypomagnesemia with Secondary Hypocalcemia]] |
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| ==References== | | ==References== |
| {{Reflist|2}} | | {{reflist|2}} |
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| == See also ==
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| * [[Calcium metabolism]]
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| * [[Hypercalcaemia]]
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| * [[Calcium deficiency (plant disorder)]]
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| * [[Hypomagnesemia with secondary hypocalcemia]]
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| ==External links==
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| * [http://www.clevelandclinicmeded.com/diseasemanagement/endocrinology/hypocal/hypocal.htm Cleveland Clinic]
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| * [http://www.endotext.org/parathyroid/parathyroid7/parathyroid7.htm Endotext]
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| * [http://www.chestjournal.org/cgi/content/full/119/2/668-a EKG abnormalities associated with hypocalcemia]
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| * [http://ndt.oxfordjournals.org/cgi/reprint/20/12/2855.pdf Seizures due to hypocalcaemia worsened by shifting towards alkalosis by bicarbonate therapy]
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| * [http://www-isu.indstate.edu/mary/lytenote.htm Electrolytes]
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| == Acknowledgements ==
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| The content on this page was first contributed by: C. Michael Gibson, M.S., M.D.
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| {{Electrocardiography}} | | {{Electrocardiography}} |
| {{SIB}}
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