Fatigue + constipation, this patient was "pulled" into the Department of Endocrinology (Part 1)

*Only for medical professionals to read for reference, have you considered this common disease? This case actually lingered in my mind for a long time, and it was only recorded now because of various reasons
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 One day at the end of summer, when I was about to end the outpatient clinic, a middle-aged male patient suddenly came in with a lover who was accompanying me
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His lover said that in the past March, the patient has experienced obvious fatigue and fatigue, and the constipation is also very serious.
It takes 1 line on 2 to 3 days.
He asked me if I can prescribe some Chinese medicine for treatment
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He has a history of type 2 diabetes for more than 20 years.
He is currently treated with insulin and oral hypoglycemic drugs, and blood sugar control is acceptable
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 Because it is a Chinese medicine hospital, many diabetic patients also come to prescribe some Chinese medicine to relieve their symptoms
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I didn't think too much about it
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It looked like when I picked up the test sheet issued by the patient in other departments .

I found that in the process of communicating with the patient, the patient's attention is not concentrated, and even slower
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His liver and kidney function tests were normal, but the blood electrolyte test sheet stated: Calcium ion 3.
42mmol/L
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Has hypercalcemia been fully hammered? Exploring the "secret" comment: Beware of the diagnosis of pseudohypercalcemia.
Hypercalcemia is one of the common clinical endocrine and metabolic disorders.
The clinical manifestations are very different.
The mild ones can be asymptomatic.
Only the routine screening finds that the blood calcium level rises.
High and severe cases can lead to coma and even life-threatening
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The normal value of adult serum calcium is 2.
25~2.
75mmol/L, higher than 2.
75mmol/L is hypercalcemia
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According to the elevated blood calcium level, hypercalcemia can be divided into mild, moderate and severe.
Mild hypercalcemia is the total blood calcium value of 2.
75~3mmol/L; moderate is 3~3.
5mmol/L; in severe cases>3.
5 mmol/L can also lead to a series of serious clinical signs, called hypercalcemia crisis, which can be life-threatening
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 When the patient's serum calcium exceeds 3.
0mmol/L, there will be obvious multi-system symptoms.
If you don't pay attention to identification, it is easy to miss the diagnosis
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High blood calcium in the digestive system can cause anorexia, weakened gastrointestinal motility, nausea, vomiting, abdominal distension, constipation, and dysphagia
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Urinary system has dry mouth, polydipsia, polyuria, and nocturia
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High levels of urinary calcium and phosphorus tend to form urinary tract stones or calcium salt deposits in the renal parenchyma
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The characteristics of urinary tract stones caused by this disease are bilateral and multiple, manifested as renal colic, hematuria or secondary urinary tract infection.
Repeated attacks can cause renal damage and lead to renal failure
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In the early stage of the skeletal system, there is only pain and local tenderness.
Long-term illness may cause vertebral compression, bone deformities, and pathological fractures
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Hypercalcemia in the neuromuscular system can cause symptoms such as fatigue, fatigue, forgetfulness, inattention, depression, and mental illness
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The cardiovascular system can cause hypertension and various arrhythmias.
The current QT interval of the ECG chart is shortened, and the ST-T segment changes
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 Generally, the diagnosis of hypercalcemia is divided into two steps.
First, determine whether there is elevated blood calcium, and then determine the cause of hypercalcemia
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It is necessary to repeat the measurement of blood calcium several times to eliminate the high blood calcium caused by laboratory errors and long tourniquet banding time.
It is also necessary to pay attention to whether the patient has dehydration and increased plasma protein concentration
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It is roughly estimated that for every increase of about 10g/L of serum protein, about 0.
2mmol/L of serum calcium will increase.

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The calculation formula of corrected calcium is: corrected calcium=measured calcium+(40-measured albumin)×0.
02, the unit of calcium concentration is mmol/L, and the unit of albumin is g/L.
This formula helps to rule out pseudohypercalcemia
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 The patient's blood albumin is 38g/L, corrected calcium=3.
42+(40-38)×0.
02=3.
46mmol/L, the guidance for hypercalcemia is real! The patient had a history of hypertension for 25 years, the highest blood pressure was 180/90mmHg, long-term use of amlodipine tablets (5mg qd) and irbesartan (0.
15g qd), blood pressure was controlled at about 120/80mmHg
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Have a history of "chronic gastritis"
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He has a history of smoking for 40 years and smokes 20 cigarettes a day
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 Physical examination after admission: body temperature 36.
5℃, blood pressure 120/70mmHg, clear consciousness, chronic appearance, no yellowing of skin and mucous membranes, no thyroid enlargement, heart rate 60 beats/min, normal rhythm, normal heart sounds, no pathological murmurs, double Lung breath sounds clear, less than dry and wet rales, soft abdomen, no tenderness and rebound pain, touch a 7cm×4cm mass under the right costal margin, smooth surface, no percussion pain in the liver area, no percussion pain in the kidney area , There is no edema in the lower limbs, the muscle strength and muscle tension of the limbs are normal, and the nervous system examination is normal
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 Auxiliary examination: blood, urine and stool routine are normal, carcinoembryonic antigen, prostate specific antigen, CA199, CA153, thyroid function and blood calcitonin are normal, glycosylated hemoglobin 6.
7%, liver and kidney function is normal, parathyroid hormone (PTH) 9.
4 pg/ml (15~65pg/ml)↓, the electrocardiogram shows sinus heart rate and ST-T segment changes
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Exploring the "secret" comment: Seek the cause, paying particular attention to the medication history.
Once the diagnosis of hypercalcemia is established, the differential diagnosis should be made from the perspective of the cause
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Calcium homeostasis in the body is mainly regulated by the three hormones PTH, calcitonin, and 1,25(OH)2-D.
The organs involved in the regulation include bones, intestines and kidneys.
Abnormalities in any link can lead to high calcium.
Blood disease
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These hormone disorders increase bone reabsorption, increase intestinal calcium absorption, or increase urinary calcium reabsorption
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May wish to simplify, according to whether the parathyroid cell function is disordered, it is divided into two categories, namely PTH-dependent hypercalcemia and PTH-independent hypercalcemia
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PTH dependence includes primary hyperparathyroidism, sporadic hyperparathyroidism, lithium-related hypercalcemia and so on
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PTH-independent neoplastic hypercalcemia, excessive intake of ordinary vitamin D or active vitamin D, granulomatous lesions (sarcoidosis, lymphoma, tuberculosis, etc.
), drugs (vitamin A, retinoic acid, thiazides) Diuretics, aminophylline, etc.
) hyperthyroidism, adrenal insufficiency, renal failure (acute and chronic), long-term immobilization, post-organ transplantation, acute pancreatitis, familial hypocalcemic hypercalcemia (calcium Receptor gene mutation) and so on
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 At present, the patient's blood PTH has decreased significantly, the cause of PTH dependence can be excluded, and the cause of non-PTH dependence needs to be considered
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The focus is to comprehensively analyze the patient's medical history, including symptoms, signs, laboratory related tests, imaging and other special examination results
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Among them, medication history is also an indispensable data in diagnosis
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I once encountered an elderly male patient with osteoporosis who took calcium (600mg elemental calcium per day) + calcitriol (0.
25µg, bid), which resulted in hypercalcemia one month later
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Ask the patient.
The patient has no history of special medication, but the patient has recently been consuming goat milk supplemented with common vitamin D, which contains 15 µg/100g milk powder
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The patient drinks about 100g of milk powder daily, that is, daily intake of 15µg of ordinary vitamin D (about 60 IU), and the maximum tolerable intake of ordinary vitamin D is 50µg (2000 IU) per day
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According to the above inference, vitamin D intake has not exceeded the standard
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 Next 25-OHD still need to improve in order to assess vitamin D levels, lung CT, calcium inspection
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Careful readers may find that a 7cm×4cm mass is touched under the right costal margin during physical examination.
What clues will this give us? Let's listen to the decomposition next time! References: [1] Xing Xiaoping.
Hypercalcemia // Chen Jialun.
Clinical Endocrinology [M].
Shanghai: Shanghai Science and Technology Press, 2011: 1385-1392.
[2] Xing Xiaoping, Kong Jing, Wang Ou.
Diagnosis and treatment of hypercalcemia crisis.
Journal of Clinical Internal Medicine, 2012, 29: 590-592.
[3]Endres DB.
Investigation of hypercalcemia[J].
Clinical Biochenistry, 2012, 45: 954-963.