Case Presentation Using Progressive Disclosure

Example slides

Patient Presents to ER

66 yr old white male Complains of progressive weakness for 2

weeks Intermittent cough, pleuritic chest pain and

exertional dyspnea for 6 days Nausea and vomiting for 2 days PTA

What questions do you ask in history?

History

hypertension coronary artery disease MI 1989 long history of heartburn

– takes 300 Tums per week and drinks a gallon of milk every other day

Physical Exam

appears weak vital signs stable oral mucosa and tongue dry Lungs: bibasilar crackles Cardiac: S3 gallop

What do you order?

Labs/X-ray

Serum Ca = 15.1 mg/dL

BUN = 65 mg/dL Creatinine = 5.9

mg/dL Intact PTH and 1,25

DihydroxyvitaminD levels were normal

Serum phosphate = 4.9 mg/dL

Serum dicarbonate = 38 mmol/L

Chest x-ray showed bilateral basilar infiltrates

What is your differiential diagnosis?

Hypercalcemia of malignancy? Primary hyperparathyroidis? Milk-alkali syndrome? Immobilization? Multiple Myeloma?

Milk-alkali Syndrome

Presents with the triad of hypercalcemia, alkalosis and renal failure Occurs in acute, subacute, and chronic

forms

Milk-alkali Syndrome

Related to excessive ingestion of calcium and absorbable antacids such as calcium carbonate and milk

First reported in 1923 – thought to be a toxic reaction to the then

popular Sippy treatment of peptic ulcer disease. The Sippy regimen: hourly administration of milk or

cream with a mixture of bicarbonate containing salts that included calcium carbonate.

Milk-alkali Syndrome

Became rare with the advent of modern ulcer therapy with nonabsorbable antacids, H2 blockers and sucralfate.

May be an increased frequency of this syndrome because of the growing popularity of over-the-counter calcium carbonate marketed either as antacids or as calcium supplements for the prevention of osteoporosis

What is your treatment plan?

Treatment Plan

Hospitalization, hydration, and diuresis Discontinue injestion of calcium IV Lasix and fluids If life threatening: short course high dose

calcitonin (Calcimar) (8 IU per kg IM Q 6-8)

Consult?

Consult?

Consult if renal failure might require dialyses.

Prevention

Milk-alkali syndrome might easily be prevented by restricting calcium intake to 1.2 to 1.5 g/day or by using a supplement that does not contain absorbable alkali.

Recent Articles

Medline search of ‘94-present yielded 10 hits. Brandwein SL, Sigman KM, Case report: milk-alkali syndrome

and pancreatitis., Am J Med Sci 308: 3, 173-6, Sep, 1994. – The relation between hypercalcemia and pancreatitis, first

described in patients with hyperparathyroidism, is controversial. Other causes of hypercalcemia also have been associated with pancreatitis. In this report, the authors describe a patient with pancreatitis and the milk-alkali syndrome who had the classic triad of hypercalcemia, alkalosis, and renal insufficiency. The authors also review the literature for all the reported cases of pancreatitis associated with hypercalcemia.

Recent Articles

Muldowney WP, Mazbar SA, Rolaids-yogurt syndrome: a 1990s version of milk-alkali syndrome., Am J Kidney Dis 27: 2, 270-2, Feb, 1996.

Milk-alkali syndrome is characterized by progressive hypercalcemia, systemic alkalosis, and renal insufficiency. After calcium carbonate is ingested with diary products, hypercalcemia and alkalosis may develop in susceptible persons, particularly those with underlying renal insufficiency. We describe a young woman who neither drank milk nor had peptic ulcer disease, yet who ingested enough calcium carbonate to require admission to an intensive care unit for acute renal failure. Chronically bulimic, she was taking Rolaids (Warner-Lambert Co, Morris Plains, NJ), which contained calcium carbonate, and was eating yogurt daily to prevent osteoporosis. We discuss the characteristics and complex metabolic interactions of the milk-alkali syndrome, a critical but generally reversible electrolyte disorder. Early recognition of coincident hypercalcemia and alkalosis and prompt cessation of calcium carbonate ingestion are essential for successful recovery. Finally, we suggest that nephrologists should discourage patients with renal insufficiency and chronic vomiting from consuming calcium-containing

antacids and excessive dietary calcium.

How do you ICD9 code this?

275 Disorders of mineral metabolism– 275.40 Disorders of calcium metabolism

hypercalcemia, calcilosis, . .

276 Disorders of fluid, electrolyte, & acid-base balance– 276.30 Alkalosis

NOS, respiratory, metabolic

– 276.50 Volume depletion disorder– 276.9 Electrolyte & fluid disorders not elsewhere classified