This document provides information on chemistry panels, including common names, components, and reference ranges for various tests. It also discusses two patient case studies. The first case involves a 36-year-old female presenting with altered mental status and seizures who is found to have severe malnutrition and liver dysfunction from alcoholism. The second case describes a 69-year-old woman with COPD and heart failure presenting with abdominal pain and swelling along with weight loss who is found to have organomegaly and ascites.
1. Chemistry Lab CaseChemistry Lab Case
StudiesStudies
Wichita State UniversityWichita State University
Jennifer Rodgers, ARNP, ACNPJennifer Rodgers, ARNP, ACNP
2. Chemistry PanelsChemistry Panels
Many names: Chem 7/Chem C/BMP (Na, K,Many names: Chem 7/Chem C/BMP (Na, K,
Cl, TCO2, Glu, BUN, Cr)Cl, TCO2, Glu, BUN, Cr)
Chem 20/Chem A/CMP (7 Plus Ca, Bili,Chem 20/Chem A/CMP (7 Plus Ca, Bili,
Protein, Albumin, Globulin, A/G Ratio, AlkProtein, Albumin, Globulin, A/G Ratio, Alk
Phos, ALT, AST)Phos, ALT, AST)
What are you looking for?What are you looking for?
Know which values to memorizeKnow which values to memorize
3. CHEMISTRY PANELCHEMISTRY PANEL
TCO2 21-32 mmol/L-Average/rough measurement ofTCO2 21-32 mmol/L-Average/rough measurement of
acid-base balanceacid-base balance
Total Protein 6.4-8.2 gm/dl-combination pre-Total Protein 6.4-8.2 gm/dl-combination pre-
albumin/albumin/globulinalbumin/albumin/globulin
Globulin 2.3-3.5 g/dl-building blocks, sign ofGlobulin 2.3-3.5 g/dl-building blocks, sign of
malnutrition & if low albumin/high Globulin/normal Tmalnutrition & if low albumin/high Globulin/normal T
protein >hepatic dysfunctionprotein >hepatic dysfunction
4. CHEMISTRY PANELCHEMISTRY PANEL
Albumin 3.5-5.0gm/dl-Albumin 3.5-5.0gm/dl-
Makes up 60% total protein, purpose maintainMakes up 60% total protein, purpose maintain
colloidal osmotic pressure , synthesized in thecolloidal osmotic pressure , synthesized in the
liver, ½ life 12-18 days- MALNUTRITIONliver, ½ life 12-18 days- MALNUTRITION
Pre-Albumin 16 to 40 mg/dlPre-Albumin 16 to 40 mg/dl
Shorter half life 2 to 3 days, excellent marker forShorter half life 2 to 3 days, excellent marker for
monitoring Nutritional Supportmonitoring Nutritional Support
5. CHEMISTRY PANELCHEMISTRY PANEL
A/G Ratio-(Albumin/Globulin) 1.5-2.2, if <1.0A/G Ratio-(Albumin/Globulin) 1.5-2.2, if <1.0
=hepatic dysfunction/SLE, if low serum/urine=hepatic dysfunction/SLE, if low serum/urine
protein electrophoresisprotein electrophoresis
Total Bili, Alk Phos, ALT, AST>cover laterTotal Bili, Alk Phos, ALT, AST>cover later
NA, K, Cl, Glu, BUN, Cr>NEED TO KNOWNA, K, Cl, Glu, BUN, Cr>NEED TO KNOW
NORMAL VALUES (where you practice),NORMAL VALUES (where you practice),
CAUSES, & NOW TO TREATCAUSES, & NOW TO TREAT
Don’t forget Magnesium levelDon’t forget Magnesium level
If Ca++ abnormal Get PhosphorusIf Ca++ abnormal Get Phosphorus
6. Case StudyCase Study
36 year old female presents to the ED with36 year old female presents to the ED with
altered mental status, + seizure at the scenealtered mental status, + seizure at the scene
when EMS arrived, multiple skin tears and Stagewhen EMS arrived, multiple skin tears and Stage
III decubitus ulcer to the coccyxIII decubitus ulcer to the coccyx
BP 90/60 P 110 RR 24 SpO2 93% on 2 litersBP 90/60 P 110 RR 24 SpO2 93% on 2 liters
What is your differential?What is your differential?
What tests do you want to order?What tests do you want to order?
7. Case StudyCase Study
PMH: + ETOH addiction, HTNPMH: + ETOH addiction, HTN
NKDANKDA
Currently not taking any medsCurrently not taking any meds
Social: Single, currently unemployed, quit job 5Social: Single, currently unemployed, quit job 5
months ago, ETOH Large amounts daily ormonths ago, ETOH Large amounts daily or
varying types of liquor, Tobacco: 10 packvarying types of liquor, Tobacco: 10 pack
history. No drugshistory. No drugs
8. Case StudyCase Study
ROS + For 50 pound weight loss in past 6ROS + For 50 pound weight loss in past 6
months (unintentional), intermittent confusion,months (unintentional), intermittent confusion,
skin tears, decubitus ulcer to coccyx, excoriationskin tears, decubitus ulcer to coccyx, excoriation
to the peri and perianal areato the peri and perianal area
Does this change your differential and tests at all?Does this change your differential and tests at all?
9. Case StudyCase Study
PE: Thin, pale, cachextic female, lethargic withPE: Thin, pale, cachextic female, lethargic with
minimal verbal responseminimal verbal response
Poor dentitionPoor dentition
Skin with pale, warm, dry with poor hygiene,Skin with pale, warm, dry with poor hygiene,
dried feces to coccyx, Stage III decub. Ulcers,dried feces to coccyx, Stage III decub. Ulcers,
multiple areas ecchymosis and skin tearsmultiple areas ecchymosis and skin tears
HRR no S3 12- Lead STHRR no S3 12- Lead ST
Abd: Soft non-tender + BS no organomegalyAbd: Soft non-tender + BS no organomegaly
Ext: trace Lower extremity edemaExt: trace Lower extremity edema
10. Case StudyCase Study
Further history from the family reveals heavyFurther history from the family reveals heavy
drinking in the past several years, particularlydrinking in the past several years, particularly
worse after her boyfriends death 7 months agoworse after her boyfriends death 7 months ago
Patient actually quit job due to drinking & hadPatient actually quit job due to drinking & had
not left the house in months, other than tonot left the house in months, other than to
purchase ETOH or have people drop it off.purchase ETOH or have people drop it off.
The home was found to have molded andThe home was found to have molded and
spoiled food, patient had been defecating onspoiled food, patient had been defecating on
herself the furniture was quite soiledherself the furniture was quite soiled
11. Case StudyCase Study
Family had attempted to get patient committedFamily had attempted to get patient committed
or other help without successor other help without success
So what kind of lab would you like to add now?So what kind of lab would you like to add now?
12. Let’s Look at the Admission Lab!Let’s Look at the Admission Lab!
Na 106 K 2.6 Mg 1.2 Ph 0.8 BUN 4 Cr 0.9 BNP 12Na 106 K 2.6 Mg 1.2 Ph 0.8 BUN 4 Cr 0.9 BNP 12
Albumin 1.4 Pre-Albumin 8 T Protein 4.2Albumin 1.4 Pre-Albumin 8 T Protein 4.2
RBC 2.63 Hgb 9.4 Fe 16RBC 2.63 Hgb 9.4 Fe 16
TSH 0.95TSH 0.95
Ammonia 16Ammonia 16
Lactic Acid 2.8Lactic Acid 2.8
CRP 12.4CRP 12.4
Ph 7.28 CO2 30 PO2 72 HCO3 14Ph 7.28 CO2 30 PO2 72 HCO3 14
13. Let’s Look at the Admission Lab!Let’s Look at the Admission Lab!
UA + for Nitrites/LeukocytesUA + for Nitrites/Leukocytes
CXR- no acute infiltrateCXR- no acute infiltrate
Head CT- negativeHead CT- negative
EEG-no seizure activityEEG-no seizure activity
Drug Screen- negativeDrug Screen- negative
ETOH 0.010ETOH 0.010
14. What should we do next?What should we do next?
ABC’s of courseABC’s of course
Bipap, Crystalloids, Consider PressorsBipap, Crystalloids, Consider Pressors
Elevated CRP + UA +Decub. UlcersElevated CRP + UA +Decub. Ulcers
Broad Spectrum Antibiotics (with anaerobe)Broad Spectrum Antibiotics (with anaerobe)
+ Vancomycin+ Vancomycin
Seizures/ETOH WithdrawalSeizures/ETOH Withdrawal
Thiamine, Folic Acid, B 12, lorazepam prnThiamine, Folic Acid, B 12, lorazepam prn
seizures, Neuro. consultseizures, Neuro. consult
15. What should we do next?What should we do next?
Electrolyte ReplacementElectrolyte Replacement
K, Mg, Ph, Na How much? How fast?K, Mg, Ph, Na How much? How fast?
Nutritional SupplementNutritional Supplement
How much? Re-feeding Syndrome?How much? Re-feeding Syndrome?
Multivitamin with Trace ElementsMultivitamin with Trace Elements
Prevent Aspiration (speech eval.)Prevent Aspiration (speech eval.)
16. What should we do next?What should we do next?
Wound SupportWound Support
Nutrition, Antibiotics, Wound Team, BedNutrition, Antibiotics, Wound Team, Bed
AnemiaAnemia
Replace Iron (IV), B12, FolateReplace Iron (IV), B12, Folate
Await culture results, follow neuro. status, cardiopulm.Await culture results, follow neuro. status, cardiopulm.
status, electrolytes closelystatus, electrolytes closely
DVT, Ulcer ProphylaxisDVT, Ulcer Prophylaxis
17. Several Days Later….Several Days Later….
Na 124 K 2.7 Ph 1.2 Mg 2.0 Cr 0.7 Hgb 9.6Na 124 K 2.7 Ph 1.2 Mg 2.0 Cr 0.7 Hgb 9.6
Core Temp. dropped to 90.6Core Temp. dropped to 90.6
WBC 2.4 Bands 60%WBC 2.4 Bands 60%
Urine + E coliUrine + E coli
Initial Blood Cultures negativeInitial Blood Cultures negative
BP 80/40 HR 50 RR 26 (shallow) SpO2 84%BP 80/40 HR 50 RR 26 (shallow) SpO2 84%
on 10 literson 10 liters
18. Several Days Later….Several Days Later….
What other tests do you want?What other tests do you want?
What is your differential?What is your differential?
What do we do next?What do we do next?
19. What Do We Do Next?What Do We Do Next?
Hypothermia-Place foley with internalHypothermia-Place foley with internal
temperature, warm fluids, warming blanket,temperature, warm fluids, warming blanket,
intubation, 12 Lead & continuous cardiacintubation, 12 Lead & continuous cardiac
monitoring, pressors if fluid alone won’tmonitoring, pressors if fluid alone won’t
maintain adequate MAPmaintain adequate MAP
Re-culture Blood, Sputum, Urine, CT Head,Re-culture Blood, Sputum, Urine, CT Head,
CXRCXR
21. Case StudyCase Study
69 year old female presents with increased69 year old female presents with increased
dyspnea, weakness, abdominal pain worseningdyspnea, weakness, abdominal pain worsening
over the past monthover the past month
BP 110/60 HR 100 RR 24 SpO2 92% 6 litersBP 110/60 HR 100 RR 24 SpO2 92% 6 liters
What is your differential?What is your differential?
What tests do you want to order?What tests do you want to order?
22. Case StudyCase Study
PMH: COPD, Chronic Hypoxemia, TobaccoPMH: COPD, Chronic Hypoxemia, Tobacco
Addiction, HTN, CADAddiction, HTN, CAD
NKDANKDA
MEDS: Oxygen, Advair 50/250 1 puff BID,MEDS: Oxygen, Advair 50/250 1 puff BID,
Proventil MDI prn, Lisinopril 10 mg PO q Day,Proventil MDI prn, Lisinopril 10 mg PO q Day,
ASA 81 mg PO q DayASA 81 mg PO q Day
Does this change your differential?Does this change your differential?
23. Case StudyCase Study
Social: Single, Retired, 60 pack history, noSocial: Single, Retired, 60 pack history, no
ETOH or drugsETOH or drugs
ROS: + 25 # unintentional weight loss,ROS: + 25 # unintentional weight loss,
constipation, abdominal swelling, lowerconstipation, abdominal swelling, lower
extremity edema, cough with intermittentextremity edema, cough with intermittent
sputum productionsputum production
24. Case StudyCase Study
PE: Ill appearing elderly female in no acutePE: Ill appearing elderly female in no acute
distress at restdistress at rest
+ cervical lymphadenopathy+ cervical lymphadenopathy
HRR + 3/6 murmurHRR + 3/6 murmur
Faint rales, non laboredFaint rales, non labored
+ spleenomegaly + hepatomegaly+ spleenomegaly + hepatomegaly
+trace LE edema+trace LE edema
Additional tests?Additional tests?
25. Lab ResultsLab Results
Na 132 K 4.0 Mg 2.0 Cr 0.8 Albumin 2.4Na 132 K 4.0 Mg 2.0 Cr 0.8 Albumin 2.4
WBC 12,000 Hgb 9.2 Plt 126,000WBC 12,000 Hgb 9.2 Plt 126,000
CXR-COPDCXR-COPD
Abd CT-Enlarged Spleen and Liver with mild ascitesAbd CT-Enlarged Spleen and Liver with mild ascites
Echo-+MR EF 40%Echo-+MR EF 40%
12 Lead SR12 Lead SR
Troponin <0.04Troponin <0.04
BNP 382BNP 382
26. What do we do next?What do we do next?
Support, ABC’s, nutrition, watch fluid status,Support, ABC’s, nutrition, watch fluid status,
low dose diuresislow dose diuresis
Get a tissue biopsy for diagnosisGet a tissue biopsy for diagnosis
Tissue Biopsy of Cervical Lymph Node revealedTissue Biopsy of Cervical Lymph Node revealed
B cell lymphomaB cell lymphoma
27. Treatment OptionsTreatment Options
Pt opted to begin chemo therapyPt opted to begin chemo therapy
Within 24 hours of chemotherapy patient beganWithin 24 hours of chemotherapy patient began
having nausea, vomiting, weakness, parasthesias,having nausea, vomiting, weakness, parasthesias,
dyspnea, and increased edemadyspnea, and increased edema
What is your differential?What is your differential?
28. What tests do we do now?What tests do we do now?
STAT Chem 7, Calcium, Phosphorus, LDH,STAT Chem 7, Calcium, Phosphorus, LDH,
Uric Acid, BNP, ABG, CXRUric Acid, BNP, ABG, CXR
Lab Results K 5.4 Cr 2.3 Ca low Ph high UricLab Results K 5.4 Cr 2.3 Ca low Ph high Uric
Acid high BNP 76 CXR Bilateral mod. PleuralAcid high BNP 76 CXR Bilateral mod. Pleural
EffusionsEffusions
What is wrong?What is wrong?
29. What do we do now?What do we do now?
Allopurinol 600-900 mg/day (PO or IV)Allopurinol 600-900 mg/day (PO or IV)
If not euvolemic Fluids goal urine 3L/day if noIf not euvolemic Fluids goal urine 3L/day if no
underlying cardiovascular issuesunderlying cardiovascular issues
NaBicarb IVNaBicarb IV
Diuretics-in well hydrated patients with hyperK+ orDiuretics-in well hydrated patients with hyperK+ or
signs of fluid overloadsigns of fluid overload
Oral phosphate binders & glucose/insulinOral phosphate binders & glucose/insulin
HypocalcemiaHypocalcemia
HemodialysisHemodialysis
30. Case StudyCase Study
56 year old female presents with increased56 year old female presents with increased
confusion, nausea, vomiting, headache,confusion, nausea, vomiting, headache,
weaknessweakness
BP 190/100 HR 50 RR 24 SpO2 92% (RA)BP 190/100 HR 50 RR 24 SpO2 92% (RA)
What is your differential?What is your differential?
What tests do you want to order?What tests do you want to order?
31. Case StudyCase Study
PMH: Tobacco Addiction, Lap Chole.,PMH: Tobacco Addiction, Lap Chole.,
Hyperlipidemia, PUDHyperlipidemia, PUD
NKDANKDA
MEDS: ASA 81 mg PO Q Day, Simvastatin 80MEDS: ASA 81 mg PO Q Day, Simvastatin 80
mg PO Q Evening, Ranitidine 150 mg PO Qmg PO Q Evening, Ranitidine 150 mg PO Q
SupperSupper
Does this change your differential?Does this change your differential?
32. Case StudyCase Study
Social: Married, Accountant, 50 pack history, noSocial: Married, Accountant, 50 pack history, no
ETOH or drugsETOH or drugs
ROS: + 15 # unintentional weight loss (perROS: + 15 # unintentional weight loss (per
family) otherwise unobtainablefamily) otherwise unobtainable
33. Case StudyCase Study
PE: Ill appearing elderly female in no acute distress atPE: Ill appearing elderly female in no acute distress at
restrest
Confused, hyperreflexiaConfused, hyperreflexia
HRR + pedal pulses + bradycardiaHRR + pedal pulses + bradycardia
Diminished breath sounds, non laboredDiminished breath sounds, non labored
Abd Soft, Non-tender + positive bowel soundsAbd Soft, Non-tender + positive bowel sounds
+ Right Axilla lymphadenopathy, palpable Right Breast+ Right Axilla lymphadenopathy, palpable Right Breast
MassMass
Additional tests?Additional tests?
34. Lab ResultsLab Results
Na 130 K 4.0 Cr 0.8 Calcium 14.3 Alb 2.8Na 130 K 4.0 Cr 0.8 Calcium 14.3 Alb 2.8
CRP 15 ESR 96CRP 15 ESR 96
WBC 15,000 Hgb 9.8 Plt 150,000WBC 15,000 Hgb 9.8 Plt 150,000
CT Head-NegativeCT Head-Negative
UA-NegativeUA-Negative
CT Breast reveals R breast massCT Breast reveals R breast mass
35. What do we do now?What do we do now?
Treat Hypercalcemia, it is a OncologicTreat Hypercalcemia, it is a Oncologic
EmergencyEmergency
Pamidronate (Aredia)Pamidronate (Aredia)
HydrateHydrate
Prevent aspiration until neuro. statusPrevent aspiration until neuro. status
improvesimproves
Breast BiopsyBreast Biopsy
Oncology ConsultOncology Consult
36. SummarySummary
The Chemistry is a common test that gives theThe Chemistry is a common test that gives the
provider excellent information if reviewedprovider excellent information if reviewed
closely.closely.
Remember, nothing takes the place of aRemember, nothing takes the place of a
thorough history & physical examination .thorough history & physical examination .
Editor's Notes
Disadvantage of Albumin is the long half life Levels of this visceral protein may decline in the setting of acute injury and illness as the liver reprioritizes protein synthesis from visceral proGibbs and colleagues[44] published the largest prospective trial, with 54,215 patients undergoing major noncardiac surgeries. Preoperative serum albumin was evaluated in relation to 30-day postoperative morbidity and mortality. Compared with nine other risk variables, serum albumin was ranked as the strongest predictor of surgical outcomes, with an inverse relationship between postoperative morbidity and mortality compared with preoperative serum albumin levels to acute-phase
reactant proteins. Synthesis also declines with hepatic insufficiency or failure.
Albumin also excellent for post op volume and if 3rd spacing Albumin/Lasix
Prealbumin, also referred to as transthyretin, is a transport protein for thyroid hormone.[37,40,41] It is synthesized by the liver and partly catabolized by the kidneys Levels may be increased in the setting of renal dysfunction, corticosteroid therapy, or dehydration, whereas physiological stress, infection, liver dysfunction, and over-hydration can decrease prealbumin levels.[8,30,37] The half-life of prealbumin (two to three days) is much shorter than that of albumin,[37,40,41] making it a more favorable marker of acute change in nutritional status. A baseline prealbumin is useful as part of the initial nutritional assessment if routine monitoring with Nutritional Support2 to is planned.
If albumin low then need to calculate Calcium
New onset seizure, cancer, dehydration, sepsis, malnutrition, ETOH addiction, suicide attempt
Chem A, ABG, CBC, CRP, Urine C & S, Blood Culture x 2, Stat Head CT, EEG, wound culture, Drug Screen, 12 lead, CXR, ETOH screen
Pre-Albumin, Vit B12, Folate, Fe, TIBC, Vit D Serum Ammonia
Tachy no Dopamine
Broad Spectrum bug juice plus Vanc until culture back
ETOH: 15.2 million Americans are alcohol dependent. There are 1.2 million hospital admissions for problems related to alcohol abuse. As many as 5% of these patients may develop delirium tremens (DT). mortality rate from severe alcohol withdrawal and DT historically has been as high as 20% if untreated. Early recognition and improved treatment has reduced the mortality rate from DT to approximately 1-5%.
Approximately 23-33% of patients with significant alcohol withdrawal have alcohol withdrawal seizures (&quot;rum fits&quot;).
Seizures are usually brief, generalized, tonic-clonic in nature, and without an aura. They occur in a cluster of 1-3 seizures with a short postictal period. Partial seizures are not uncommon. In 30-50% of patients, the seizures progress to DT.
The incidence peaks 24 hours after the most recent alcohol ingestion.
Most seizures typically terminate spontaneously or are easily controlled with benzodiazepines.
Determine what type of hyponatremia
Many experts recommend that serum Na be raised no faster than 1 mEq/L/h, but replacement rates of up to 2 mEq/L/h for the first 2 to 3 h have been suggested for patients with seizures. Regardless, the rise should be ≤ 10 mEq/L over the first 24 h. More vigorous correction risks precipitation of osmotic demyelination syndrome (previously central pontine myelinolysis) may follow too-rapid correction of hyponatremia. Demyelination may affect the pons and other areas of the brain. Lesions are more common in patients with alcoholism, undernutrition, or other chronic debilitating illness. Flaccid paralysis, dysarthria, and dysphagia can evolve over a few days or weeks. The lesion may extend dorsally to involve sensory tracts and leave patients with a locked-in syndrome (an awake and sentient state in which patients, because of generalized motor paralysis, cannot communicate, except possibly by coded eye movements). Damage often is permanent. When Na is replaced too rapidly (eg, &gt; 14 mEq/L/8 h) and neurologic symptoms start to develop, it is critical to prevent further serum Na increases by stopping hypertonic fluids. In such cases .
in the presence of arrhythmias, K+ can be replaced intravenously by a solution containing 40 to 60 meq/l, infused at a rate of no more than 40 meq/hour. Any magnesium deficiency must be corrected in order to reverse hypoMg++ consider KPhos Phosphate is necessary for the generation of adenosine triphosphate from adenosine diphosphate and adenosine monophosphate and other crucial phosphorylation reactions. Serum phosphate concentrations of less than 0.50 mmol/l (normal range 0.85-1.40 mmol/l) can produce the clinical features of refeeding syndrome, which include rhabdomyolysis, leucocyte dysfunction, respiratory failure, cardiac failure, hypotension, arrhythmias, seizures, coma, and sudden death.4,5 Importantly
Nutrition Refeeding syndrome characterized by is characterized by hypophosphatemia, hypokalemia, and hypomagnesemia. And often thiamine def. (enteral or parenteral), this should be started at a reduced calorific rate (25-50% of estimated requirements) to reduce the risk of refeeding syndrome developing. Serum phosphate, magnesium, calcium, potassium, urea, and creatinine concentrations should be measured before feeding and repeated daily for four days after feeding is started. When hypophosphataemia occurs it should be corrected in addition to other electrolyte abnormalities, such as hypokalaemia and hypomagnesaemia
ABG Repeat Cultures CXR Head CT Tropi TSH Free T4
Pneumonia Sepsis CVA MI Myxedema Coma, osmotic demyelination syndrome
21% mortality rate for patients with moderate hypothermia with higher mortality rates include homelessness, alcoholism, psychiatric disease, and advanced age.&quot;Indoor hypothermia&quot; is more likely to occur in patients with significant medical comorbidities (alcoholism, sepsis, hypothyroidism/hypopituitarism) and tends to carry worse outcomes than exposure hypothermia
Afebrile
CHF, Cancer, Pneumonia, IBS,
CBC, Chem A, Tropi, BNP, Abd Xray, CXR 12-lead
Cancer moves up on my list
Abd CT, Echo
HF with exac, aspiration, Acute Renal Failure,TLS
TLS, HF w EXac Acute Renal Failure
Drawbacks to systemic alkaline therapy include magnification of clinical hypocalcemia by shifting ionized calcium to its nonionized form. Increased likelihood of calcium phosphate precipitation in renal tubules is an additional drawback. For these reasons, routine urine alkalinization is controversial, and if it is employed, it must include close monitoring of urinary pH, serum bicarbonate, and uric acid levels to both guide therapy and avoid overzealous alkalinization. Consider withdrawing sodium bicarbonate from intravenous fluid solutions once serum bicarbonate levels reach 30 mEq/L, urinary pH exceeds 7.5, or serum uric acid levels have normalized.
Glucose/insulin like in hyperk
Hypocalcemia- as a rule don’t replace unless neuromuscular irritability exists, as indicated by a positive Chvostek or Trousseau sign. Usually corrects as phosphorus does
Hemodialysis-if above mentioned fail
Stop ACE
Watch and Wait
Pamidronate (Aredia)
60 to 90 mg IV infusion
Corticosteroids certain malignancies (eg, multiple myeloma, lymphoma), sarcoidosis, and other granulomatous diseases. These agents generally are not effective in patients with solid tumors or primary hyperparathyroidism. Several different glucocorticoids may be used.