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<div class="noeditbox">Welcome to [[Pathophysiology of Complex Patient Problems|PT 635 Pathophysiology of Complex Patient Problems]] This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
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'''Original Editors '''- Robbie Esterle &amp; Ryan Hamilton [[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  
'''Original Editors '''- Robbie Esterle &amp; Ryan Hamilton [[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  


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== Definition/Description<ref>The Medical Dictionary. Available at http://medical-dictionary.thefreedictionary.com/hypocalcemia. Accessed on 2013 April 7</ref><ref name="medscape">Medscape Reference. Hypocalcemia. Available at http://emedicine.medscape.com/article/241893-overview. Accessed 2013 April 7.</ref><br> ==
== Introduction ==
[[File:Nursing Home limited sun.jpg|thumb|Nursing home, limited sun exposure.]]
Hypocalcemia, a low [[Blood Physiology|blood]] calcium level, occurs when the concentration of free calcium ions in the blood falls below 4.4 mg/dL.  <ref>The Medical Dictionary. Available at http://medical-dictionary.thefreedictionary.com/hypocalcemia. Accessed on 2013 April 7</ref><ref name="medscape">Medscape Reference. Hypocalcemia. Available at http://emedicine.medscape.com/article/241893-overview. Accessed 2013 April 7.</ref> It can cause symptoms like tingling, muscle cramps, and [[Heart Arrhythmias: Assessment|heart arrhythmia]]<nowiki/>s, that can range from mild to life-threatening.


Hypocalcemia, a low bood calcium level, occurs when the concentration of free calcium ions in the blood falls below 4.4 mg/dL. The normal concentration of free calcium ions in the blood serum is 4.4-5.4 mg/dL. <br>  
Hypocalcemia is particularly a problem for people who are hospitalized or institutionalised.<ref name=":0" />


== Prevalence <ref name="clinicalkey">ClinicalKey. Hypocalcemia. Available at https://www.clinicalkey.com/topics/endocrinology/hypocalcemia.html. Accessed 2013 April 7</ref> ==
== Epidemiolgy ==
Incidence and prevalence are difficult to estimate because hypocalcemia is a multifactorial diagnosis<ref name="clinicalkey">ClinicalKey. Hypocalcemia. Available at https://www.clinicalkey.com/topics/endocrinology/hypocalcemia.html. Accessed 2013 April 7</ref>.


Incidence and prevalence are difficult to estimate because hypocalcemia is a multifactorial diagnosis. Postsurgical hypoparathyroidism is decreasing as thyroid and parathyroid surgery techniques improve.&nbsp;
Hypocalcemia is particularly a problem for people who are hospitalized.<ref name=":0">Very well health Hypocalcemia Available: https://www.verywellhealth.com/hypocalcemia-overview-4774539<nowiki/>(accessed 3.4.2022)</ref>A 2018 study found 27.72% of inpatients had  Hypocalcemia<ref>Catalano A, Chilà D, Bellone F, Nicocia G, Martino G, Loddo I, Morabito N, Benvenga S, Loddo S. [https://www.sciencedirect.com/science/article/pii/S2214623718300413 Incidence of hypocalcemia and hypercalcemia in hospitalized patients: Is it changing?.] Journal of clinical & translational endocrinology. 2018 Sep 1;13:9-13. Available: https://www.sciencedirect.com/science/article/pii/S2214623718300413<nowiki/>(accessed 3.4.2022)</ref>.
== Etiology ==
[[File:Parathyroid hormone.png|thumb|To maintain homeostasis, PTH regulates calcium levels in blood]]
Chronic hypocalcemia is commonly due to inadequate levels of parathyroid hormone (PTH) or [[Vitamin D Deficiency|vitamin D]] (from food or limited sun exposure) or due to resistance to these [[hormones]].<ref name=":1">Fong J, Khan A. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279267/ Hypocalcemia: updates in diagnosis and management for primary care]. Canadian family physician. 2012 Feb 1;58(2):158-62. Available;https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279267/ (accessed 3.4.2022)</ref> Low levels of PTH can be due to injury to the parathyroid gland from surgery or radiation treatment, autoimmune disease, or a genetic disease leading to low PTH.  


Decreases in total serum calcium are quite common in ill patients, but ionized calcium typically remains normal.
Other causes include:Medical conditions eg Celiac disease, pancreatitis, and kidney or liver disease; Certain medicines, eg diuretics, proton pump inhibitors, medicines to prevent seizures<ref name=":0" />
== Clinical Presentation ==
Sometimes symptoms are relatively mild, other times they may cause life-threatening problems. In someone who is already critically ill, having hypocalcemia may increase a person’s risk of death.<ref name=":0" />


== Characteristics/Clinical Presentation<ref name="medscape">http://emedicine.medscape.com/article/241893-overview</ref><br>  ==
* Acute hypocalcemia can result in severe symptoms requiring hospitalization
* Patients who gradually develop hypocalcemia are more likely to be asymptomatic.
* Symptoms of hypocalcemia most commonly include paresthesia, muscle spasms, cramps, tetany, circumoral numbness, and seizures.
* Hypocalcemia can also present with laryngospasm, neuromuscular irritability, [[Cognitive Impairments|cognitive impairment]], personality disturbances, [[Electrocardiogram|prolonged QT intervals]], electrocardiographic changes that mimic [[Myocardial Infarction|myocardial infarction]], or [[Heart Failure|heart failure]]<ref name=":1" />


In neonates, hypocalcemia is more likely to occur in infants born of diabetic or preeclamptic mothers. Hypocalcemia also may occur in infants born to mothers with hyperparathyroidism.&nbsp; Clinically evident hypocalcemia generally presents in milder forms and is usually the result of a chronic disease state. In emergency department patients, chronic or subacute complaints secondary to mild or moderate hypocalcemia are more likely to be a chief complaint than severe symptomatic hypocalcemia.&nbsp; In an elderly patient, a nutritional deficiency may be associated with a low intake of vitamin D. A history of alcoholism can help diagnose hypocalcemia due to magnesium deficiency, malabsorption, or chronic pancreatitis.&nbsp; Acute hypocalcemia may lead to syncope, congestive heart failure, and angina due to the multiple cardiovascular effects.&nbsp; Neuromuscular and neurologic symptoms may also occur.<br>Neuromuscular symptoms include the following:<br>
== Diagnosis ==
Involves


*Numbness and tingling sensations in the perioral area or in the fingers and toes
* Evaluation of signs, symptoms, and the medicines history.
*Muscle cramps, particularly in the back and lower extremities; may progress to carpopedal spasm (ie, tetany)
* Objective: Chvostek sign, facial twitch obtained by tapping the distribution of the facial nerve in front of the tragus. Caused by mechanical irritability of peripheral nerves. It is indicative of hypocalcaemia and is the most reliable test for hypocalcaemia.
*Wheezing; may develop from bronchospasm
* [[Blood Tests|Blood tests]] to check calcium, magnesium, and [[Hormones|hormone]] levels.&nbsp;
*Dysphagia
*Voice changes (due to laryngospasm)


Neurologic symptoms of hypocalcemia include the following:<br>
== Treatment ==
 
Treatment focuses on oral calcium and vitamin D supplements, as well as magnesium if deficiency is present. Treatment can be further intensified with thiazide [[diuretics]], phosphate binders, and a low-salt and low-phosphorus diet when treating hypocalcemia secondary to hypoparathyroidism. Acute and life-threatening calcium deficit requires treatment with intravenous calcium.<ref name=":1" />
*Irritability, impaired intellectual capacity, depression, and personality changes
*Fatigue
*Seizures (eg, grand mal, petit mal, focal)
*Other uncontrolled movements
 
Chronic hypocalcemia may produce the following dermatologic manifestations:<br>
 
*Coarse hair
*Brittle nails
*Psoriasis
*Dry skin
*Chronic pruritus
*Poor dentition
*Cataracts<br>
 
== Associated Co-morbidities <ref name="clinicalkey" />  ==
 
*Epilepsy (in adults or in children): hypocalcemia secondary to anticonvulsant therapy
*HIV: hypocalcemia due to calcium chelation in foscarnet therapy
*Chronic liver disease: defective hydroxylation of vitamin D  
*Intestinal malabsorption
*Tuberculosis: isoniazid therapy<br>
 
== Medications <ref name="medscape" />  ==
 
*Calcium chloride
*Calcium Gluconate
*Calcium carbonate
*Calcium citrate
*Calcitrol
*Vitamin D<br>
 
== Diagnostic Tests/Lab Tests/Lab Values <ref name="medscape" /><ref name="clinicalkey" />  ==
 
Acute hypocalcemia causes prolongation of the QT interval, which may lead to ventricular dysrhythmias (see the image below). <ref name="medscape" /><br>
 
[[Image:EKG.jpg|thumb|center]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <ref name="medscape" />
 
Hypocalcemia needs confirmation, if there is any doubt, by measurement of the serum ionized calcium level. When the diagnosis is confirmed by the finding of a serum calcium level lower than 8.2 mg/dL (2.05 mmol/L) or an ionized calcium level lower than 4.4 mg/dL (1.1 mmol/L), attention should turn toward seeking the cause.<ref name="clinicalkey" /><br>
 
<br>
 
*Serum calcium levels less than 8.2 mg/dL or ionized calcium levels less than 4.4 mg/dL.*
 
== Etiology/Causes&nbsp;<ref name="medscape" /><br>  ==
 
The causes of hypocalcemia include the following:
 
*Hypoalbuminemia
*Hypomagnesemia
*Hyperphosphatemia
*Multifactorial enhanced protein binding and anion chelation
*Medication effects
*Surgical effects
*PTH deficiency or resistance
*Vitamin D deficiency or resistance<br>
 
== Systemic Involvement <ref name="medscape" />  ==
 
'''Acute hypocalcemia''' may lead to syncope, congestive heart failure (CHF), and angina due to the multiple cardiovascular effects. Neuromuscular and neurologic symptoms may also occur.
 
Neuromuscular symptoms include the following:
 
Numbness and tingling sensations in the perioral area or in the fingers and toes<br> Muscle cramps, particularly in the back and lower extremities; may progress to carpopedal spasm (ie, tetany)<br> Wheezing; may develop from bronchospasm<br> Dysphagia<br> Voice changes (due to laryngospasm)
 
Neurologic symptoms of hypocalcemia include the following:
 
Irritability, impaired intellectual capacity, depression, and personality changes<br> Fatigue<br> Seizures (eg, grand mal, petit mal, focal)<br> Other uncontrolled movements
 
'''Chronic hypocalcemia''' may produce the following dermatologic manifestations:
 
Coarse hair<br> Brittle nails<br> Psoriasis<br> Dry skin<br> Chronic pruritus<br> Poor dentition<br> Cataracts
 
== Medical Management (current best evidence) <ref name="medscape" />  ==
 
Most hypocalcemic emergencies are mild and require only supportive treatment and further laboratory evaluation. On occasion, severe hypocalcemia may result in seizures, tetany, refractory hypotension, or arrhythmias that require a more aggressive approach.<br>In the emergency department, magnesium and calcium (in their many different forms) are the only medications necessary to treat hypocalcemic emergencies. The consulting endocrinologist may choose to prescribe any of the various vitamin D supplements depending on laboratory workup findings, and oral calcium supplementation for outpatient therapy.<br>
 
== Physical Therapy Management (current best evidence)  ==
 
Due to the nature of hypocalcemia being secondary to a primary disease state, physical therapy management includes recognition of the signs and symptoms thereof. Appropriate action taken and appropriate referral.<br>
 
== Alternative/Holistic Management (current best evidence) <ref>Healthaliciousness.com. Top 10 Highest Foods in Calcium. Available at http://www.healthaliciousness.com/articles/foods-high-in-calcium.php. Accessed 2013 April 7.</ref>  ==
 
A diet high in calcium.&nbsp; Foods that are high in calcium are dairy products, tofu, almonds, flaxseed, green leafy vegetables, herring, and dried herbs such as poppy seed, oregano, rosemary, etc. &nbsp;
 
<br>
 
[[Image:Dairy-Products.jpg|thumb|center|http://www.guidinginstincts.com/2011/04/can-dairy-products-damage-your-health.html]]<br>  


== Physiotherapy ==
Due to the nature of hypocalcemia being secondary to a primary disease state, physical therapy management includes recognition of the signs and symptoms thereof. Appropriate action taken and appropriate referral.[[File:Calcium Homeostasis.jpeg|thumb|Calcium Homeostasis|alt=|center|524x524px]]
<br>
<br>
== Differential Diagnosis <ref name="medscape" />  ==
*Acute Renal Failure
*Hydrofluoric Acid Burns
*Hyperparathyroidism
*Hyperphosphatemia
*Hypoalbuminemia
*Hypomagnesemia
*Hypoparathyroidism
*Metabolic Alkalosis
*Pancreatitis, Acute


== Case Reports/ Case Studies  ==
== Case Reports/ Case Studies  ==


#Shulman R, O'gorman CS, Sochett EB. Case 1: Neonate with seizures and hypocalcemia. Paediatr Child Health. 2008;13(3):197-200. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2529411/ www.ncbi.nlm.nih.gov/pmc/articles/PMC2529411/]<br>
#Dawrant J, Pacaud D. Pediatric hypocalcemia: making the diagnosis. CMAJ. 2007;177(12):1494-7. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2096479/ www.ncbi.nlm.nih.gov/pmc/articles/PMC2096479/]<br>
#Fong J, Khan A. Hypocalcemia: updates in diagnosis and management for primary care. Can Fam Physician. 2012;58(2):158-62. [http://www.cfp.ca/content/58/2/158.full www.cfp.ca/content/58/2/158.full]<br>
#Fong J, Khan A. Hypocalcemia: updates in diagnosis and management for primary care. Can Fam Physician. 2012;58(2):158-62. [http://www.cfp.ca/content/58/2/158.full www.cfp.ca/content/58/2/158.full]<br>
<br>
== Resources <br>  ==
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== References  ==
== References  ==


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Latest revision as of 11:16, 17 February 2023

Original Editors - Robbie Esterle & Ryan Hamilton from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Robert Esterle, Ryan Hamilton, Lucinda hampton, Admin, Elaine Lonnemann, Kim Jackson, 127.0.0.1 and Wendy Walker  

Introduction[edit | edit source]

Nursing home, limited sun exposure.

Hypocalcemia, a low blood calcium level, occurs when the concentration of free calcium ions in the blood falls below 4.4 mg/dL. [1][2] It can cause symptoms like tingling, muscle cramps, and heart arrhythmias, that can range from mild to life-threatening.

Hypocalcemia is particularly a problem for people who are hospitalized or institutionalised.[3]

Epidemiolgy[edit | edit source]

Incidence and prevalence are difficult to estimate because hypocalcemia is a multifactorial diagnosis[4].

Hypocalcemia is particularly a problem for people who are hospitalized.[3]A 2018 study found 27.72% of inpatients had Hypocalcemia[5].

Etiology[edit | edit source]

To maintain homeostasis, PTH regulates calcium levels in blood

Chronic hypocalcemia is commonly due to inadequate levels of parathyroid hormone (PTH) or vitamin D (from food or limited sun exposure) or due to resistance to these hormones.[6] Low levels of PTH can be due to injury to the parathyroid gland from surgery or radiation treatment, autoimmune disease, or a genetic disease leading to low PTH.

Other causes include:Medical conditions eg Celiac disease, pancreatitis, and kidney or liver disease; Certain medicines, eg diuretics, proton pump inhibitors, medicines to prevent seizures[3]

Clinical Presentation[edit | edit source]

Sometimes symptoms are relatively mild, other times they may cause life-threatening problems. In someone who is already critically ill, having hypocalcemia may increase a person’s risk of death.[3]

  • Acute hypocalcemia can result in severe symptoms requiring hospitalization
  • Patients who gradually develop hypocalcemia are more likely to be asymptomatic.
  • Symptoms of hypocalcemia most commonly include paresthesia, muscle spasms, cramps, tetany, circumoral numbness, and seizures.
  • Hypocalcemia can also present with laryngospasm, neuromuscular irritability, cognitive impairment, personality disturbances, prolonged QT intervals, electrocardiographic changes that mimic myocardial infarction, or heart failure[6]

Diagnosis[edit | edit source]

Involves

  • Evaluation of signs, symptoms, and the medicines history.
  • Objective: Chvostek sign, facial twitch obtained by tapping the distribution of the facial nerve in front of the tragus. Caused by mechanical irritability of peripheral nerves. It is indicative of hypocalcaemia and is the most reliable test for hypocalcaemia.
  • Blood tests to check calcium, magnesium, and hormone levels. 

Treatment[edit | edit source]

Treatment focuses on oral calcium and vitamin D supplements, as well as magnesium if deficiency is present. Treatment can be further intensified with thiazide diuretics, phosphate binders, and a low-salt and low-phosphorus diet when treating hypocalcemia secondary to hypoparathyroidism. Acute and life-threatening calcium deficit requires treatment with intravenous calcium.[6]

Physiotherapy[edit | edit source]

Due to the nature of hypocalcemia being secondary to a primary disease state, physical therapy management includes recognition of the signs and symptoms thereof. Appropriate action taken and appropriate referral.

Calcium Homeostasis


Case Reports/ Case Studies[edit | edit source]

  1. Fong J, Khan A. Hypocalcemia: updates in diagnosis and management for primary care. Can Fam Physician. 2012;58(2):158-62. www.cfp.ca/content/58/2/158.full

References[edit | edit source]

  1. ↑ The Medical Dictionary. Available at http://medical-dictionary.thefreedictionary.com/hypocalcemia. Accessed on 2013 April 7
  2. ↑ Medscape Reference. Hypocalcemia. Available at http://emedicine.medscape.com/article/241893-overview. Accessed 2013 April 7.
  3. ↑ 3.0 3.1 3.2 3.3 Very well health Hypocalcemia Available: https://www.verywellhealth.com/hypocalcemia-overview-4774539(accessed 3.4.2022)
  4. ↑ ClinicalKey. Hypocalcemia. Available at https://www.clinicalkey.com/topics/endocrinology/hypocalcemia.html. Accessed 2013 April 7
  5. ↑ Catalano A, Chilà D, Bellone F, Nicocia G, Martino G, Loddo I, Morabito N, Benvenga S, Loddo S. Incidence of hypocalcemia and hypercalcemia in hospitalized patients: Is it changing?. Journal of clinical & translational endocrinology. 2018 Sep 1;13:9-13. Available: https://www.sciencedirect.com/science/article/pii/S2214623718300413(accessed 3.4.2022)
  6. ↑ 6.0 6.1 6.2 Fong J, Khan A. Hypocalcemia: updates in diagnosis and management for primary care. Canadian family physician. 2012 Feb 1;58(2):158-62. Available;https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279267/ (accessed 3.4.2022)


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