Case Presentation Using Progressive Disclosure

1. Case Presentation Using Progressive Disclosure Florida State University College of Medicine “Sample Case Presentation”

2. 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? Florida State University College of Medicine “Sample Case Presentation”

3. 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 Florida State University College of Medicine “Sample Case Presentation”

4. Physical Exam • appears weak • vital signs stable • oral mucosa and tongue dry • Lungs: bibasilar crackles • Cardiac: S3 gallop What do you order? Florida State University College of Medicine “Sample Case Presentation”

5. 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 Labs/X-ray Florida State University College of Medicine “Sample Case Presentation”

6. What is your differiential diagnosis? • Hypercalcemia of malignancy? • Primary hyperparathyroidis? • Milk-alkali syndrome? • Immobilization? • Multiple Myeloma? Florida State University College of Medicine “Sample Case Presentation”

7. Milk-alkali Syndrome Presents with the triad of • hypercalcemia, • alkalosis and • renal failure • Occurs in acute, subacute, and chronic forms Florida State University College of Medicine “Sample Case Presentation”

8. 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. Florida State University College of Medicine “Sample Case Presentation”

9. 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 Florida State University College of Medicine “Sample Case Presentation”

10. What is your treatment plan? Florida State University College of Medicine “Sample Case Presentation”

11. 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? Florida State University College of Medicine “Sample Case Presentation”

12. Consult? • Consult if renal failure might require dialyses. Florida State University College of Medicine “Sample Case Presentation”

13. 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. Florida State University College of Medicine “Sample Case Presentation”

14. Recent ArticlesMedline 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 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. Florida State University College of Medicine “Sample Case Presentation”

15. 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 How do you ICD9 code this? Florida State University College of Medicine “Sample Case Presentation”