Case Presentation of a Practical Problem in Family

1. Case Presentation Using
Progressive Disclosure
Example slides

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?

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

4. Physical Exam
 appears weak
 vital signs stable
 oral mucosa and tongue dry
 Lungs: bibasilar crackles
 Cardiac: S3 gallop
What do you order?

5. 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

6. What is your differiential
diagnosis?
 Hypercalcemia of malignancy?
 Primary hyperparathyroidis?
 Milk-alkali syndrome?
 Immobilization?
 Multiple Myeloma?

7. Milk-alkali Syndrome
Presents with the triad of
 hypercalcemia,
 alkalosis and
 renal failure
 Occurs in acute, subacute, and chronic
forms

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.

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

10. What is your treatment plan?

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?

12. Consult?
 Consult if renal failure might require
dialyses.

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.

14. 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.

15. 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.

16. 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