Normal Calcium levels in women:

Total calcium 911 mg/dL or 4.55.5 mEq/L 911 mg/dL or 4.55.5 mEq/L

Ionized calcium 4.25.4 mg/dL or 2.12.6 mEq/L 4.25.4 mg/dL or 2.12.6 mEq/L

In the case the patients serum levels was 4mg/100ml (note: 100ml = 1dl) Per this case the patient is hypocalcemic causing the twitching on the extremities. Causes of hypocalcemia:
Low Total Calcium - Hypocalcemia

The most common cause of low total calcium is: Low blood protein levels, especially a low level of albumin. In this condition, only the bound calcium is low. Ionized calcium remains normal and calcium metabolism is being regulated appropriately. Some other causes of hypocalcemia include: Underactive parathyroid gland (hypoparathyroidism) Inherited resistance to the effects of parathyroid hormone Extreme deficiency in dietary calcium Decreased levels of vitamin D Magnesium deficiency Increased levels of phosphorus Acute inflammation of the pancreas (pancreatitis) tumor in the pancrease Renal failure Malnutrition Alcoholism

What is Zollinger-Ellison syndrome (ZES)? ZES is a rare disorder characterized by one or more tumors in the pancreas, duodenum, or both. The tumors cause the stomach to make too much acid, leading to peptic ulcers in the duodenum. The tumors are sometimes cancerous and spread to other areas of the body. Clinical manifestation in hypocalcemia:
What Are Some Symptoms of Hypocalcemia To Look For? The most common sign of hypocalcemia is what is called "neuromuscular irritability." Your nerves and muscles, which are directly related to blood calcium levels, may spasm or twitch. (as was seen in the case of this patient) If your blood test results indicate hypocalcemia, you may notice muscle cramps in your legs or your arms. The symptoms of hypocalcemia you experience may relate to how fast or how slowly the fall in blood calcium levels occur. o If you have long-standing low blood calcium levels, you may notice no symptoms of hypocalcemia.

o If you have an "acute" or sudden drop in your blood calcium level, you may notice more twitching. You may notice, with mildly lowered blood calcium levels, numbness and tingling of your fingers and toes. You may notice that you are depressed, or more irritable if you have mildly low hypocalcemia. With severely lowered blood calcium levels, you may become confused or disoriented. Your heart muscle may contract irregularly due to the electrolyte disturbance.

Treatment: CALCIUM GLUCONATE (which was given to the patient in this case)

CALCIUM GLUCONATE
(gloo'koe-nate) Kalcinate Classifications: FLUID AND ELECTROLYTIC AND WATER BALANCE AGENT; REPLACEMENT
SOLUTION

Pregnancy Category: B

Availability
500 mg, 650 mg, 975 mg, 1 gm tablets; 10% injection

Actions
Calcium is an essential element for regulating the excitation threshold of nerves and muscles, for blood clotting mechanisms, cardiac function (rhythm, tonicity, contractility), maintenance of renal function, for body skeleton and teeth. Also plays a role in regulating storage and release of neurotransmitters and hormones; regulating amino acid uptake and absorption of vitamin B12, gastrin secretion, and in maintaining structural and functional integrity of cell membranes and capillaries. Calcium gluconate acts like digitalis on the heart, increasing cardiac muscle tone and force of systolic contractions (positive inotropic effect).

Therapeutic Effects
Rapidly and effectively restores serum calcium levels in acute hypocalcemia of various origins and effective cardiac stabilizer under conditions of hyperkalemia or resuscitation.

Uses
Negative calcium balance (as in neonatal tetany, hypoparathyroidism, vitamin D deficiency, alkalosis). Also to overcome cardiac toxicity of hyperkalemia, for cardiopulmonary resuscitation, to prevent hypocalcemia during transfusion of citrated blood. Also as antidote for magnesium sulfate, for acute symptoms of lead colic, to decrease capillary permeability in sensitivity reactions, and to relieve muscle cramps from insect bites or stings. Oral calcium may be used to maintain normal calcium balance during pregnancy, lactation, and childhood growth and to

prevent primary osteoporosis. Also in osteoporosis, osteomalacia, chronic hypoparathyroidism, rickets, and as adjunct in treatment of myasthenia gravis and Eaton-Lambert syndrome.

Unlabeled Uses
To antagonize aminoglycoside-induced neuromuscular blockage, and as "calcium challenge" to diagnose Zollinger-Ellison syndrome and medullary thyroid carcinoma.

Contraindications
Ventricular fibrillation, metastatic bone disease, injection into myocardium; administration by SC or IM routes; renal calculi, hypercalcemia, predisposition to hypercalcemia (hyperparathyroidism, certain malignancies); pregnancy (category B).

Cautious Use
Digitalized patients, renal or cardiac insufficiency, sarcoidosis, history of lithiasis, immobilized patients; lactation.

Route & Dosage

All doses are in terms of elemental calcium: 1 g calcium gluconate = 90 mg (4.5 mEq, 9.3%) elemental calcium
Supplement for Osteoporosis

Adult: PO 12 g b.i.d. to q.i.d. IV 7 mEq q13d Child: PO 4565 mg/kg/d in divided doses. IV 17 mEq q13d Neonate: PO 50130 mg/kg/d (max: 1 g) IV mEq q13d
Hypocalcemic Tetany

Adult: IV 4.516 mEq prn Child: IV 0.50.7 mEq/kg t.i.d. or q.i.d. Neonate: IV 2.4 mEq/kg/d in divided doses
CPR

Adult: IV 2.33.7 mEq x 1

Hyperkalemia with Cardiac Toxicity

Adult: IV 2.2514 mEq q 12 min

Exchange Transfusions with Citrated Blood

Adult: IV 1.35 mEq for each 100 mL of blood Neonate: IV 0.45 mEq for each 100 mL of blood