CASE ANALYSIS

I. PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA
1. Patients Name: L.J
2. Address: Quezon city
3. Age: 45
4. Sex: Female
5. Birth Date: March 27,, 1960
6. Rank in the Family: Second child
7. Nationality: Filipino
8. Civil Status: Married
9. Date of Admission: January 27,2014
10. Final diagnosis: hypocalcaemia
11. Attending Physician: Dr. Osias
B. CHIEF COMPLAINT:
Tingling sensation and numbness of all extremities (fingers and toes)
C. NURSING HISTORY:
Sept 27,2014 patient walked in theto emergency room with a complaints of no feeling of sensation in upper and lower extremities
Hypocalcaemia or hypocalcemia is the presence of low serum calcium levels in the blood. Physiologically, blood calcium is tightly regulated within a narrow
range for proper cellular processes. Calcium in the blood exists in three primary states: bound to proteins (mainly albumin), bound to anions such as phosphate
and citrate, and as free (unbound) ionized calcium. Only the ionized calcium is physiologically active.
Normal blood calcium level is between 8.5 to 10.5 mg/dL (2.12 to 2.62 mmol/L) and that of ionized calcium is 4.65 to 5.25 mg/dL (1.16 to 1.31 mmol/L). Common
causes of hypocalcemia include
hypoparathyroidism,

vitamin D deficiency, and

chronic kidney disease.

Symptoms of hypocalcemia include neuromuscular irritability (including tetany as manifested by Chvostek's sign or Trousseau's sign, bronchospasm),
electrocardiographic changes, and seizures. Treatment is dependent upon the cause, but most commonly includes supplementation of calcium and some form of
vitamin D or its analogues.
Signs and symptoms[edit]
The neuromuscular symptoms of hypocalcemia are caused by a positive bathmotropic effect due to the decreased interaction of calcium with sodium channels.
Since calcium blocks sodium channels and inhibits depolarization of nerve and muscle fibers, [clarification needed] diminished calcium lowers the threshold for
depolarization.[1] The symptoms can be recalled by the mnemonic "CATS go numb"- Convulsions, Arrhythmias, Tetany and numbness/parasthesias in hands, feet,
around mouth and lips.

Petechiae which appear as on-off spots, then later become confluent, and appear as purpura (larger bruised areas, usually in dependent regions of
the body).

Oral, perioral and acral paresthesias, tingling or 'pins and needles' sensation in and around the mouth and lips, and in the extremities of the hands and
feet. This is often the earliest symptom of hypocalcaemia.

Carpopedal and generalized tetany (unrelieved and strong contractions of the hands, and in the large muscles of the rest of the body) are seen.

Latent tetany

Trousseau sign of latent tetany (eliciting carpal spasm by inflating the blood pressure cuff and maintaining the cuff pressure above systolic)

Chvostek's sign (tapping of the inferior portion of the cheekbone will produce facial spasms)[2]

Tendon reflexes are hyperactive

Life-threatening complications

Laryngospasm

Cardiac arrhythmias

ECG changes include the following:

Intermittent QT prolongation, or intermittent prolongation of the QTc (corrected QT interval) on the EKG (electrocardiogram) is noted. The
implications of intermittent QTc prolongation predisposes to life-threatening cardiac electrical instability (and this is therefore a more critical condition

than constant QTc prolongation). This type of electrical instability puts the patient at high risk of torsades de pointes, a specific type of ventricular
fibrillation which appears on an EKG (or ECG) as something which looks a bit like a sine wave with a regularly increasing and decreasing amplitude.
(Torsades de pointes, as with any type of ventricular tachycardia, causes death, unless the patient can be electrically cardioverted, and returned to a
normal cardiac rhythm.)

Causes
Hypoparathyroidism is a common cause of hypocalcemia. Calcium is tightly regulated by the parathyroid hormone (PTH). In response to low calcium levels, PTH
induces the kidneys to reabsorb calcium, the kidneys to increase production of calcitriol (the active form of vitamin D) thereby increasing intestinal absorption of
calcium, and the bones to release calcium. These actions lead to a re-balance in the blood calcium levels. However, in the setting of absent, decreased, or
ineffective PTH hormone, the body loses this regulatory function, and hypocalcemia ensues. Hypoparathyroidism is commonly due to surgical destruction of the
parathyroid glands via parathyroidectomy, partial or total thyroidectomy, or neck dissection for head and neck cancers. Hypoparathyroidism may also be due to
autoimmune destruction of the glands.
Eating disorders
Prolonged vomiting (eg with a viral illness)
Exposure to mercury, including infantile acrodynia
Excessive dietary magnesium, as with supplementation.[citation needed]
Excessive dietary zinc, as with supplementation (causes rapid hypocalcemia).
Prolonged use of medications/laxatives containing magnesium
Chelation Therapy for metal exposure, particularly EDTA
Osteoporosis treatment or preventive agents, such as Bisphosphonates and Denosumab.
Agents for the treatment of hypercalcemia, such as Calcitonin.
Chronic renal failure
Absent active vitamin D

Decreased dietary intake

Decreased sun exposure

Defective Vitamin D metabolism

Anticonvulsant therapy

Vitamin-D dependent rickets, type I

Ineffective active vitamin D

Intestinal malabsorption

Vitamin-D dependent rickets, type II

Pseudohypoparathyroidism
Severe acute hyperphosphataemia
Tumour lysis syndrome
Acute renal failure

Rhabdomyolysis (initial stage)

Exposure to hydrofluoric acid

As a complication of pancreatitis
Alkalosis, often caused by hyperventilation

As blood plasma hydrogen ion concentration decreases, caused by respiratory or metabolic alkalosis, the concentration of freely ionized calcium,
the biologically active component of blood calcium, decreases. Because a portion of both hydrogen ions and calcium are bound to serum albumin, when
blood becomes alkalotic, the bound hydrogen ions dissociate from albumin, freeing up the albumin to bind with more calcium and thereby decreasing the
freely ionized portion of total serum calcium. For every 0.1 increase in pH, ionized calcium decreases by about 0.05 mmol/L. This hypocalcaemia related
to alkalosis is partially responsible for the cerebral vasoconstriction that causes the lightheadedness, fainting, and paraesthesia often seen
with hyperventilation.
Tetany may also be seen with this condition.

Neonatal hypocalcemia

Very low birth weight (less than 1500 grams)

Gestational age less than 32 weeks

E. PATHOPHYSIOLOGY:

Family history of hypocalcemia

Low-calcium diet
Lack of sun exposure
Recent surgery .
DIAGNOSTIC PROCEDURES: CBC with PC, PT/PTT, CT/BT
HEMATOLOGY:
Hemoglobin = 96
Hematocrit =0.29
Leukocyte =18.40
ESR = 89
Interpretation: there is an increase in the number of leukocyte and ESR which indicates presence of infection and inflammation. While the hemoglobin and
hematocrit are decreased which indicates dehydration or fluid volume deficit.
Medications

Radiocontrast
Estrogen
Loop diuretics
Bisphosphonates
Calcium supplements
Antibiotics
Antiepileptic drugs
Cinacalcet
ASSESSMENT
Neurologic symptoms of hypocalcemia include the following [33] :

Irritability, impaired intellectual capacity, depression, and personality changes

Fatigue
Seizures (eg, grand mal, petit mal, focal)
Other uncontrolled movements
Chronic hypocalcemia may produce the following dermatologic manifestations:

Coarse hair
Brittle nails
Psoriasis
Dry skin
Chronic pruritus
Poor dentition
Cataracts
Physical Examination
Neuromuscular and cardiovascular findings predominate. Neural hyperexcitability due to acute hypocalcemia causes smooth and skeletal muscle contractions. In
addition, patients may appear confused or disoriented and may exhibit signs of dementia or overt psychosis. Irritability, confusion, hallucinations, dementia,
extrapyramidal manifestations, and seizures may occur.
On head and neck examination, the hair may appear coarse, and alopecia may be present. Signs of recent trauma or of surgery of the neck (eg, scars over the
thyroid region) should be noted. Perioral anesthesia may be present, and adults with chronic (since childhood) hypocalcemia may be at an increased risk for dental
caries and enamel hypoplasia. On eye examination, subcapsular cataracts or papilledema may be seen.
On respiratory examination, inspiratory or expiratory wheezes may be present. Smooth muscle contraction may lead to laryngeal stridor, dysphagia, and
bronchospasm. On cardiac examination, bradycardia, tachycardia, S 3, and signs of heart failure may be present.[34]
Dry skin or patches of psoriasis and eczema may be present, particularly in patients with chronic hypocalcemia. Excoriations as a result of pruritus may be noted.
Test for Chvostek sign by tapping the skin over the facial nerve about 2 cm anterior to the external auditory meatus. Ipsilateral contraction of the facial muscles is a
positive sign. Depending on the calcium level, a graded response will occur: twitching first at the angle of the mouth, then by the nose, the eye, and the facial
muscles. Up to 10% of the population will have a positive Chvostek sign in the absence of hypocalcemia; thus, this test, while suggestive, is not diagnostic of
hypocalcemia.
Test for the Trousseau sign by placing a blood pressure cuff on the patients arm and inflating to 20 mm Hg above systolic blood pressure for 3-5 minutes. This
increases the irritability of the nerves, and a flexion of the wrist and metacarpal phalangeal joints can be observed with extension of the interphalangeal joints and
adduction of the thumb (carpal spasm). The Trousseau sign is more specific than the Chvostek sign but has incomplete sensitivity.
Movement abnormalitiesassociated with hypocalcemia include the following:

Choreoathetosis[35]
Dystonic spasm
Parkinsonism
Hemiballism
Peripheral nervous system findings include tetany, focal numbness, and muscle spasms. Smooth muscle contraction causes biliary colic, intestinal colic, and
dysphagia. Seizures often occur in individuals with preexistent epileptic foci when the excitation threshold is lowered.