40 Questions
Which of the following is NOT a presenting symptom highlighted in the 'bones, stones, moans, and groans' mnemonic?
Fever
What is the most reliable laboratory test to detect hypercalcemia?
Measuring ionized calcium
When measuring total calcium, which of the following is important to consider?
Correcting for hypoalbuminemia
What is the likely more significant factor in determining whether a patient becomes symptomatic from hypercalcemia?
The rate of calcium increase
Which of the following is NOT a potential sign or symptom of hypercalcemia?
Tachycardia
What is the effect of hypercalcemia on the QT interval?
Shortens the QT interval
Which of the following can cause abdominal pain in the setting of hypercalcemia?
All of the above
What is the relationship between hypercalcemia and kidney stone formation?
Even in the setting of profound hypercalciuria, not all patients will form kidney stones, which may be due to differences in the urine mineral concentration needed to precipitate calculi
Which of the following cancers is least likely to cause hypercalcemia despite frequently metastasizing to bone?
Prostate cancer
Which range is considered normal for serum calcium levels?
2.1-2.6 mmol/L
Which of the following is the most common cause of hypercalcemia among hospitalized patients?
Malignancy
Which of the following mechanisms can lead to hypercalcemia in cancer patients?
Bone metastases producing factors that stimulate osteoclasts, leading to bone resorption
Which of the following statements is true regarding the symptoms of hypercalcemia?
The symptoms are non-specific, and delayed recognition can worsen morbidity and mortality
Which of the following cancers is most likely to cause hypercalcemia through bone metastases?
Metastatic breast cancer
Which of the following body systems can be affected by oncological emergencies?
All of the above
Which of the following conditions is classified as a metabolic oncological emergency?
Hypercalcemia
What is the role of measuring parathyroid hormone-related peptide (PTHrP) in initial management of hypercalcemia?
It has not been proven to affect outcome and should not guide initial management
Which test is considered more readily available to support a diagnosis of humoral hypercalcemia?
Serum chloride levels
What effect can PTHrP have on endogenous parathyroid hormone (PTH) levels in patients with humoral hypercalcemia?
Decrease PTH levels
What is the cornerstone of initial management for hypercalcemia?
Hydration
At what rate can normal saline be safely infused in a patient with hypercalcemia if they have intact left ventricular systolic function?
Up to 500 mls/hour
Which medication can be initiated to promote calciuresis after volume depletion has been corrected in a patient with hypercalcemia?
Loop diuretics
What is the suggested interval for administering furosemide intravenously in a patient with hypercalcemia for promoting calciuresis?
Every 12-24 hours
When should urgent intervention be considered in a patient with hypercalcemia?
Urgent intervention is always needed regardless of calcium levels
What is the mechanism by which antidiuretic hormone promotes free water uptake in the distal tubules?
Binding to the vasopressin 2 (V2) receptor
What can contribute to continued free water intake in euvolemic hyponatremic patients with cancer?
Suppressed thirst mechanism
Where is SIADH more commonly encountered based on the location of primary and metastatic tumors?
Lungs, pleura, thymus, and brain
Which of the following cancers has a significant percentage of patients showing evidence of SIADH?
Small cell lung cancer
Which of the following drugs can cause SIADH as an iatrogenic cause of hyponatremia?
Cisplatin
How does SIADH primarily affect the extracellular fluid volume in euvolemic hyponatremic patients with cancer?
Reflects appropriate total sodium content but excessive water in intravascular space
What is the primary issue with the thirst mechanism in euvolemic hyponatremic patients with cancer?
Insufficient inhibition of thirst mechanism
What is the etiology of hyponatremia in patients receiving potentially causative medications such as cisplatin?
Platinum-induced salt-wasting nephropathy
Which statement is true regarding the use of thiazide diuretics in managing hypercalcemia?
They should be avoided as they increase calcium reabsorption from the urine.
Which of the following statements about hemodialysis is true, according to the text?
It may be a faster and less hazardous method of correcting hypercalcemia in patients with diminished kidney function.
Which of the following statements is true regarding the use of glucocorticoids in managing hypercalcemia?
They are useful in mediating the release of cytokines and prostaglandins that stimulate osteoclasts.
Which of the following nursing assessments is NOT mentioned in the text for managing hypercalcemia?
Auscultating lung sounds.
Which of the following statements is true regarding fluid management in hypercalcemia?
Encourage fluid intake of 3 to 4 liters per day, including sodium-containing fluids (within cardiac tolerance).
Which of the following nursing interventions is NOT mentioned in the text for managing hypercalcemia?
Administering supplemental oxygen therapy.
Which of the following statements is true regarding the assessment of hyponatremia in cancer patients?
It requires a critical determination of volume status, as in all patients.
Which of the following statements is NOT true based on the information provided in the text?
Thiazide diuretics are recommended for managing hypercalcemia.
Study Notes
Hypercalcemia
- Presents with skeletal pain, nephrolithiasis, abdominal discomfort, and altered mentation
- Mnemonic: "bones, stones, moans, and groans"
- Bone pain usually due to discrete metastasis rather than diffuse calcium liberation
- Abdominal pain can arise from dysregulated intestinal motility, pancreatitis, or severe constipation
- Changes in sensorium can occur along a spectrum from lethargy to coma
- Hypercalcemia shortens QT interval and can produce cardiac arrhythmias
- Other signs and symptoms include fatigue, lethargy, constipation, stupor, and coma
Diagnosis
- Ionized calcium is the most reliable laboratory test to detect hypercalcemia (>1.29 mmol/L)
- Total calcium levels should be corrected for hypoalbuminemia
- No absolute level of calcium at which patients become symptomatic; rate of increase likely more significant than magnitude of elevation
Pathophysiology
- Hypercalcemia affects up to one-third of cancer patients
- Most common causes: breast, lung, and renal cell carcinomas; multiple myeloma; and adult T-cell leukemia/lymphoma
- Bone metastases can cause local paracrine effect, leading to bone resorption and hypercalcemia
- Prostate cancer rarely causes hypercalcemia
Management
- Hydration is the cornerstone of initial management
- Correction of volume depletion helps restore urine output
- Loop diuretics can be initiated to promote calciuresis
- Glucocorticoids can help mediate the release of cytokines and prostaglandins that stimulate osteoclasts
- Hemodialysis may be a faster and less hazardous method of correcting hypercalcemia in patients with diminished kidney function
Nursing Management
- Assess level of consciousness and neuromuscular status
- Monitor cardiac rate and rhythm, and be aware of cardiac arrest risk
- Monitor intake and output, and calculate fluid balance
- Encourage fluid intake of 3-4 liters per day, including sodium-containing fluids
- Promote frequent repositioning and range-of-motion exercises with caution
Hyponatremia
- Assessment requires critical determination of volume status
- Euvolemic hyponatremic patients have normal extracellular fluid volume but excessive water in the intravascular space
- SIADH is suspected in patients with lung, pleura, thymus, or brain tumors
- Iatrogenic causes of hyponatremia include cisplatin, cyclophosphamide, ifosfamide, vinca alkaloids, and imatinib
Test your knowledge on hypercalcemia, a high calcium level in the blood serum, as part of metabolic oncological emergencies. Learn about the normal range of calcium levels and the implications of hypercalcemia on the body systems.
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