Sodium Abnormalities

Hypernatremia

2/8

Video & Symbols

“145”-shaped elephant on peanut-shaped cloud

Hypernatremia = serum sodium > 145 mEq/L (ultimately represents a net LOSS of free
water compared to serum sodium)

“145”-shaped elephant on peanut-shaped cloud:

Hypernatremia = serum sodium > 145 mEq/L (ultimately represents a net LOSS of free
water compared to serum sodium)

Elderly elephant + baby elephant:

Elderly patients and very young patients are most at risk of hypernatremia due to lack of
access to water (very young, very old, immobilized, long term care facilities) or loss of thirst
response (dementia); patients with intact thirst response and access to fresh water should
not develop hypernatremia, as high sodium stimulates thirst response ( → increased free
water intake), and ADH release ( → kidneys preserve free water)

Confused and irritable elephant with brain hat + alarm clock:

Acute hypernatremia (<48) or significantly elevated hypernatremia (Na >160) is associated
with neurological symptoms of confusion, altered mental status, lethargy, irritability, muscle
weakness, hyperreflexia, seizures and coma

Happy grandfather clock:

Chronic hypernatremia (lasting >48 hours) may be asymptomatic or present with very mild,
nonspecific symptoms

Raining brain-shaped cloud:

Hypernatremia causes osmotic fluid to shift out of brain → decreased brain volume
(shrinkage)

Red lightning in brain-shaped cloud:

Osmotic fluid loss of brain volume → intracranial hemorrhages (subdural and intracerebral)
due to venous rupture

Cracked + falling kite beads:

Osmotic fluid shifting out of brain → osmotic demyelination due to osmotic destruction of
myelin sheath cells (oligodendrocytes)

Empty trough, dry hay + salty peanuts:

Dehydration (net loss of free water instead of loss of volume) causes confusion, lethargy,
hypotension, tachycardia, poor skin turgor, dry mucous membranes, and delayed capillary
refill

Peeing and drinking with nightcap:

Symptoms of diabetes insipidus as a cause of hypernatremia = polyuria, polydipsia, and

nocturia

Rainbow vomit, diarrhea + sweat:

Unreplaced hypotonic fluid loss (e.g. GI losses (vomiting, diarrhea, NG tube suction), skin
losses (excessive sweating, burns) = extrarenal cause of hypernatremia

Elderly + young elephants:

Lack of access to water (very elderly or very young, AMS, dementia, immobilization, thirst
impairment) = extrarenal cause of hypernatremia

Salty peanut pile:

Sodium overload (e.g. sodium poisoning, hypertonic saline use) = extrarenal cause of
hypernatremia
Peeing and drinking with nightcap:

Diabetes insipidus = renal cause of hypernatremia

Kidney-cloud + candy pile:

Osmotic diuresis (from diabetic ketoacidosis (DKA) or hyperosmolar hyperosmolar

syndrome (HHS), or from certain diuretics) = renal cause of hypernatremia

Lesson

Sodium Abnormalities

Hyponatremia: Clinical Presentation & DDx

2/8

Video & Symbols

Brain hair + tight headband + shake lines + green face paint

Signs/symptoms of hyponatremia = neurologic symptoms (e.g. headache, confusion,

irritability, seizures, coma), nausea/vomiting)

Brain hair + tight headband + shake lines + green face paint:

Signs/symptoms of hyponatremia = neurologic symptoms (e.g. headache, confusion,

irritability, seizures, coma), nausea/vomiting)

Brain wig springing from clown’s head:

Most feared complication of hyponatremia = brain herniation

Concentrated polka dots on high trapeze:

Hypertonic hyponatremia (serum Osm >295 mOsm/kg)

Candy trapeze:

Causes of hypertonic hyponatremia = severe hyperglycemia (e.g. DKA/HHS)

Tall man on stilts:

Causes of hypertonic hyponatremia = IV mannitol

Balanced tightrope walker + evenly-spaced polka dots:

Isotonic hyponatremia (serum Osm = 280-295 mOsm/kg)

Raspberry sorbet:

Causes of isotonic hyponatremia = irrigation with isotonic glycine and/or sorbitol (during
urologic or gynecologic surgery)

Fatty barbell + antibody weights:

Causes of isotonic hyponatremia = pseudohyponatremia from severe hypertriglyceridemia

(e.g. acute pancreatitis, DKA) or hyperproteinemia (e.g. multiple myeloma, Waldenstrom’s
macroglobulinemia)

Sparse polka dots on lowest performer:

Hypotonic hyponatremia (serum Osm < 280 mOsm/kg)

Low trunk spray:

Hypovolemic [hypotonic] hyponatremia

Pea“Na+”s in yellow water:

For hypovolemic hyponatremia, order a urine Na+ to differentiate between extrarenal and
renal losses

Elephant w/ > 40 blanket + kidney ears:

Urine Na+ > 40 mEq/L from renal losses → hypovolemic hyponatremia

#1 adrenal beanie:

Causes of hypovolemic hyponatremia (w/ ↑ urine Na+) = 1˚ adrenal insufficiency

Pale thighs of elephant:

Causes of hypovolemic hyponatremia (w/ ↑ urine Na+) = thiazide diuretics

Loop tail of elephant:

Causes of hypovolemic hyponatremia (w/ ↑ urine Na+) = loop diuretics

Lesson

Sodium Abnormalities

Hyponatremia: Workup & Management

2/8

Video & Symbols

Fishbone

Obtain metabolic panel

Fishbone:

Obtain metabolic panel

Honey:

Obtain glucose (serum)

Polka dots on red leotard:

Obtain serum osmolality

Tall man:

Serum osmolal gap >10 mosm/kg = presence of unmeasured osmotically-active substances

(e.g. mannitol, sorbitol, glycine)
11-shaped stilts + gap:

Serum osmolal gap >10 mosm/kg = presence of unmeasured osmotically-active substances

(e.g. mannitol, sorbitol, glycine)

Crinkly lipid fries:

Obtain lipid panel (serum)

Chicken wings:

Obtain protein levels (serum)

Salty pea“Na+”s in yellow pool:

Obtain urine Na+

Yellow ribbon with polka dots:

Obtain urine osmolality

Salty pea“Na+”s in water cannon:

Give hypertonic saline for acute or severely symptomatic hyponatremia

6-shaped cannon firing salty peanuts in water:

Acute hyponatremia requires faster correction rate (4 to 6 mEq/L over a few hours) to
improve neurologic symptoms and prevent brain herniation

Sunny alarm clock set to 2:00:

Acute hyponatremia = hyponatremia occurring for less than 2 days

Grandfather clock set to 3:00:

Chronic hyponatremia = hyponatremia occurring for greater than 2 days

0.5 elephant pendulum:

Max correction rate for chronic hyponatremia patients with mild to moderate symptoms = 0.5
mEq/L/hr

Unraveling myelin tape:

Osmotic demyelination syndrome is caused by rapid correction of sodium, which causes

fluid to shift out of brain cells
Lesson

Potassium Abnormalities

Hyperkalemia: Clinical Presentation & DDx

2/8

Video & Symbols

“5imian 5afari”

Normal potassium level is approx 3.5 - 5 mEq/L; Hyperkalemia is a serum potassium ≥ 5.5
mEq/L and symptomatic hyperkalemia usually occurs ≥ 6.5

“5imian 5afari”:

Normal potassium level is approx 3.5 - 5 mEq/L; Hyperkalemia is a serum potassium ≥ 5.5
mEq/L and symptomatic hyperkalemia usually occurs ≥ 6.5

Acid yellow pool:

Metabolic acidosis can result from hyperkalemia secondary to reduced urinary ammonium
excretion

Paralyzed researcher with heart coming out of his chest:

Hyperkalemia can cause cardiac arrhythmias including bradycardia, AFib/VFib and asystole,
as well as muscle weakness that can progress to ascending flaccid paralysis

T-stemmed elevated bananas:

EKG changes seen in hyperkalemia include peaked T waves, shortening of QT, QRS
widening and progression to a sine wave

Bridge wobbling up and down:

EKG changes seen in hyperkalemia include peaked T waves, shortening of QT, QRS
widening and progression to a sine wave

Monkey throwing bananas through canopy:

Transcellular potassium shift can be a mechanism for the development of hyperkalemia

Yellow “+” hat:

Metabolic acidosis will cause hydrogen to move into the cell, and potassium to move out into
the serum which can lead to hyperkalemia

Torn pant:

Increased tissue breakdown secondary to trauma, tumor lysis syndrome or rhabdomyolysis

can lead to hyperkalemia

Muted beta-bugle:

Beta blockers, digoxin toxicity, calcineurin inhibitors and succinylcholine can all lead to
hyperkalemia

DJ Foxglove mixtape:

Beta blockers, digoxin toxicity and succinylcholine can all lead to hyperkalemia

Candy key:

DKA, HHS & Insulin deficiency can lead to hyperkalemia

Dominoes:

Hyperkalemic periodic paralysis is an autosomal dominant inherited cause of hyperkalemia

Tourist holding bananas crashing into kidney-shaped fruit:

Impaired urinary K+ excretion can be a mechanism for the development of hyperkalemia

Stolen mineral crystals:

Mineralocorticoid deficiency and low aldosterone can be a cause of hyperkalemia; it can be

inherited (as in congenital 21-hydroxylase deficiency) or acquired (as in primary adrenal
insufficiency, aka Addison’s disease)
Lesson

Potassium Abnormalities

Hyperkalemia: Management

2/8

Video & Symbols

Fake monkey suit + bananas

Pseudohyperkalemia can result from technique used during lab draw (drawing from line near
potassium infusion, hemolysis, prolonged tourniquet, delayed processing, sample cooling) or
elevated platelets or WBC

Fake monkey suit + bananas:

Pseudohyperkalemia can result from technique used during lab draw (drawing from line near
potassium infusion, hemolysis, prolonged tourniquet, delayed processing, sample cooling) or
elevated platelets or WBC

Continuous EKG vine:

Continuous cardiac monitoring and frequent EKGs are essential to monitor cardiac rhythm
and morphology changes

Briefcase with test tubes:

Labs (assess renal function, WBC, PLTs, glucose, calcium level). Also consider specific
situations (digoxin level, CPK/myoglobin if rhabdomyolysis suspected, uric acid if tumor lysis
suspected, and aldosterone if mineralocorticoid deficiency suspected
Monkeys with 6.5-shaped tails:

Rapid emergent correction needed in symptomatic hyperkalemia, K>6.5, or K>5.5 with

continued risk factors

Researcher calming monkey with ice cream:

First step is to stabilize cellular membrane with IV calcium; generally calcium gluconate is
preferred as it can be given peripherally

Packing bananas into boxes:

Shift potassium into cells

Box labeled “INSIDE” & ”Go Bananas for Nature’s Candy”:

Insulin shifts potassium into cells and glucose decreases likelihood of hypoglycemia

Beta bugle:

Beta-2 agonists (albuterol, for example) shifts K into cells by increasing Na-K ATPase activity

Baking soda bicarb fog:

In patients with metabolic acidosis, sodium bicarbonate ↑pH & activates Na+-K+-pump

Researcher pulling banana from monkey:

Remove potassium from the body

Monkey with large thighs & looped tail:

Thiazide & loop diuretics; potassium wasting diuretics remove potassium from body

Zirconium earring:

Sodium zirconium cyclosilicate (GI cation exchanger) is preferred over older polystyrene
sulfonate which is less effective, and can cause colonic necrosis

AEIOU dialysis machine:

If severe renal impairment → dialysis may be indicated to lower potassium

“Mild-mannered monkeys– limit bananas”:

If hyperkalemia is mild or chronic, less urgent correction needed, may consider diet and
medication adjustment (trials of diuretics or chronic GI cation exchangers)
Lesson

Potassium Abnormalities

Hypokalemia: Clinical Presentation & DDx

2/8

Video & Symbols

Fallen banana peels

Hypokalemia <3.5 mEq/L (normal reference range for potassium is 3.5 - 5 mEq/L) and
severe hypokalemia is less than 2.5 mEq/L

Fallen banana peels:

Hypokalemia <3.5 mEq/L (normal reference range for potassium is 3.5 - 5 mEq/L) and
severe hypokalemia is less than 2.5 mEq/L

Explorer crouched in tight ball:

Severe hypokalemia can cause muscle weakness, muscle cramping, rhabdomyolysis

Bulge in snake belly:

Ileus can occur with hypokalemia and can result in abdominal distention, abdominal pain,
constipation, nausea and vomiting

Passed out explorer:

More profound hypokalemia can lead to more severe muscular symptoms including flaccid
paralysis, hyporeflexia and respiratory depression secondary to weakness
Heart beating out of chest:

Hypertension and various arrhythmias can occur with hypokalemia including PACs/PVCs,
bradycardia, junctional tachycardias, Vtach/Vfib and Torsades de pointe

Chimp pulling end of EKG vine up:

EKG changes in hypokalemia include U waves (commonly in V4-6), ST segment depression,

flattened or flipped T waves, prolonged QT, prolonged PR and enlarged P waves

Chimp flattening mushroom with foot:

EKG changes in hypokalemia include U waves (commonly in V4-6), ST segment depression,

flattened or flipped T waves, prolonged QT, prolonged PR and enlarged P waves

Depressed chimp pulling down on ST segment:

EKG changes in hypokalemia include U waves (commonly in V4-6), ST segment depression,

flattened or flipped T waves, prolonged QT, prolonged PR and peaked P waves

Chimp stashing bananas in tree:

Transcellular shift is a way potassium leaves the serum and moves into the cell via the Na-
K-ATPase pump

INside door mat:

Insulin causes potassium to be moved inside the cell by directly stimulating the Na-K-
ATPase pump

Beta-bugle:

Increased beta adrenergic activity causes potassium to shift intracellularly. Examples include
medications like albuterol, ephedrine, pseudoephedrine

Chimp paralyzed with fear:

Hypokalemic periodic paralysis is an inherited or acquired disorder that can cause sudden
recurrent attacks of generalized muscle weakness secondary to rapid intracellular shift of
potassium; severe cases can be fatal

Domino:

Hereditary hypokalemic periodic paralysis is autosomal dominant

Vine bowtie:

Acquired hypokalemic periodic paralysis can be secondary to thyrotoxicosis

Lesson

Potassium Abnormalities

Hypokalemia: Management

2/8

Video & Symbols

EKG vine

Obtain EKG, glucose, metabolic panel, & magnesium level

EKG vine:

Obtain EKG, glucose, metabolic panel, & magnesium level

Candy:

Obtain EKG, glucose, metabolic panel, & magnesium level

Fishbone:

Obtain EKG, glucose, metabolic panel, & magnesium level

Magazine:

Obtain EKG, glucose, metabolic panel, & magnesium level

Banana waterfall off renal rock with sun rising:

Obtaining a 24-hr urine K collection will help distinguish between renal causes vs other
causes (transcellular shift, GI losses)
Higher pool of yellow water:

In the setting of metabolic acidosis & ↑urinary potassium, hypokalemia may be due to renal
tubular acidosis, DKA or a carbonic anhydrase inhibitor

Lower pool of yellow water with chimp having diarrhea:

In the setting of metabolic acidosis & ↓ urinary potassium, hypokalemia may be due to
diarrhea; consider infectious diarrhea, laxative abuse, villous adenoma, VIPoma

Higher pool of blue water with mother and baby:

Metabolic alkalosis & ↑ urinary potassium can indicate hypokalemia is due to inherited
tubulopathies (specifically Bartter and Gitelman) or due to loop and thiazide diuretics

Minerals/crystals & Kidney-shaped rocks with vines high on wall:

Metabolic alkalosis & ↑ urinary potassium with ↑ BP may indicate the cause of hypokalemia
is due to excess mineralocorticoids (hyperaldosteronism, Cushings) or renovascular disease

Chimp vomiting in lower pool of blue water:

Metabolic alkalosis & ↓urinary potassium may indicate the cause of hypokalemia is vomiting;
could be due to NG tube losses, bulimia, infectious vomiting

Ranger at her station:

Potassium repletion can be PO or IV, will raise serum potassium 0.1 mEq/L for every 10
mEq given and should be accompanied by magnesium repletion, if indicated

“No Dextrose!” sign on bus:

Dextrose → increased insulin release → intracellular K shift → worsening hypokalemia

Pay >$3.30 to go INSIDE:

In DKA, K level must be ＞3.3 before insulin is given; additional potassium supplementation
should occur concurrently

Tourist on top of bus:

Cardiac and cirrhotic patients should be optimized to a K of 4

Lesson

Calcium Abnormalities

Hypercalcemia: Clinical Presentation

2/8

Video & Symbols

High shelf milk carton with happy cow

The majority of hypercalcemia is found incidentally, and patients are either asymptomatic or
minimally symptomatic

High shelf milk carton with happy cow:

The majority of hypercalcemia is found incidentally, and patients are either asymptomatic or
minimally symptomatic

Sick crab tank worker:

Consider malignancy in patients with acute symptomatic hypercalcemia

Cracked fish bone:

Signs/symptoms of hypercalcemia = bone pain

Kidney-shaped stone:

Signs/symptoms of hypercalcemia = nephrolithiasis

Clutching abdomen + green face:

Signs/symptoms of hypercalcemia = abdominal pain, nausea, vomiting, constipation (rarely
pancreatitis, peptic ulcers)

Brain bandana:

Signs/symptoms of hypercalcemia = neuropsychiatric symptoms (e.g. fatigue, weakness,

anxiety, depression, lethargy and coma)

Water filling tank:

Signs/symptoms of hypercalcemia: polyuria → hypovolemia

Low volume line:

Signs/symptoms of hypercalcemia: polyuria → hypovolemia

Falling reflex hammer:

Signs/symptoms of hypercalcemia = ↓ deep tendon reflexes

Acutely ringing alarm clock:

Acute hypercalcemia (e.g. malignancy) → more dramatic presentation

Lesson

Calcium Abnormalities

Hypercalcemia: Workup & DDx

2/8

Video & Symbols

Inventory checklist

Recheck calcium levels (total + ionized) to confirm hypercalcemia

Inventory checklist:

Recheck calcium levels (total + ionized) to confirm hypercalcemia

Employee album:

Order albumin to calculate total corrected calcium; for every 1 g drop in albumin below 4
g/dL → add 0.8 mg/dL to the measured total calcium

Standing PthD:

PTH-dependent hypercalcemia = ↑ or high-normal PTH, ↑ calcium (serum)

#1 ribbon:

Causes of PTH-dependent hypercalcemia = primary hyperparathyroidism (PHPT) (MOST

COMMON etiology, usually parathyroid adenoma)

3 calci-yum treats on kidney-shaped plate:

Causes of PTH-dependent hypercalcemia = tertiary hyperparathyroidism 2/2 chronic kidney

disease (CKD)

Parent + infant with wet stain:

Causes of PTH-dependent hypercalcemia = familial hypocalciuric hypercalcemia (FHH)

Crossed out calci-yum ice cream sign on 24 hour “Family Restroom”:

Urine calcium < 100 mg/day on 24 hour urinary calcium excretion test → FHH

forkLIft holding up milk boxes:

Causes of PTH-dependent hypercalcemia = lithium

Fallen PthD badge:

PTH-independent hypercalcemia = ↓ or low-normal PTH, ↑ calcium (serum)

PTHrP kid:

Causes of PTH-independent hypercalcemia = humoral hypercalcemia of malignancy (↑

PTHrP)

Blood-red crab:
Causes of PTH-independent hypercalcemia = humoral hypercalcemia of malignancy (↑
PTHrP); e.g. squamous cell carcinomas of lung, head, or neck, breast, ovarian, renal, and
bladder carcinomas

Bone-breaking crab:

Causes of PTH-independent hypercalcemia = osteolytic metastases; e.g. breast cancer is

most common

1, 25 - Calcitron robot:

Causes of PTH-independent hypercalcemia = extrarenal production by granulomatous

diseases (↑ 1, 25-dihydroxyvitamin D3); e.g. lymphoma, sarcoidosis

Soccer ball:

Causes of PTH-independent hypercalcemia = extrarenal production by granulomatous

diseases (↑ 1, 25-dihydroxyvitamin D3); e.g. lymphoma, sarcoidosis

B-shaped bows + T-shaped knight chess pieces:

Causes of PTH-independent hypercalcemia = extrarenal production by granulomatous

diseases (↑ 1, 25-dihydroxyvitamin D); e.g. lymphoma, sarcoidosis

Lesson

Calcium Abnormalities

Hypercalcemia: Management

2/8

Video & Symbols

Printing excess PthD stickers

Most common cause of hypercalcemia = high PTH from primary hyperparathyroidism 2/2
parathyroid adenoma

Printing excess PthD stickers:

Most common cause of hypercalcemia = high PTH from primary hyperparathyroidism 2/2
parathyroid adenoma

PthD intern + glandular buttons:

Most common cause of hypercalcemia = high PTH from primary hyperparathyroidism 2/2
parathyroid adenoma

Scalpel scissors:

Parathyroidectomy is indicated for symptomatic primary hyperparathyroidism 2/2 parathyroid

adenoma

14 L milk bottle:

Treatment of severe hypercalcemia (serum calcium > 14 mg/dL) or symptomatic

hypercalcemia = IV isotonic normal saline, calcitonin, bisphosphonate

IVy plant + icy tonic bottles:

Treatment of severe hypercalcemia (serum calcium > 14 mg/dL) or symptomatic

hypercalcemia = IV isotonic normal saline

“C-tones”:

Treatment of severe hypercalcemia (serum calcium > 14 mg/dL) or symptomatic

hypercalcemia = calcitonin

“To Donate”:

Treatment of severe hypercalcemia (serum calcium > 14 mg/dL) or symptomatic

hypercalcemia = bisphosphonate (e.g. zoledronic acid)

Dancing man doing dino dance:

Treatment of severe hypercalcemia (serum calcium > 14 mg/dL) or symptomatic

hypercalcemia = denosumab (for patients who can’t take or don’t respond to
bisphosphonates)

“Dialyzer”:

Patients with severe hypercalcemia and underlying renal insufficiency or heart failure should
receive hemodialysis
Shriveled kidney-shaped plate:

Patients with severe hypercalcemia and underlying renal insufficiency or heart failure should
receive hemodialysis

Floppy heart balloon:

Patients with severe hypercalcemia and underlying renal insufficiency or heart failure should
receive hemodialysis

Lesson

Calcium Abnormalities

Hypocalcemia: Clinical Presentation & DDx

2/9

Video & Symbols

Fallen ice cream cone

Hypocalcemia is serum level < 8.5

Fallen ice cream cone:

Hypocalcemia is serum level < 8.5

“Free milk sign”:

Free ionized calcium is active; Bound calcium is inactive and is mostly bound to albumin
(small amount bound to phosphate, citrate)
Boxed up milk:

Free ionized calcium is active; Bound calcium is inactive and is mostly bound to albumin
(small amount bound to phosphate, citrate)

Blue binding straps:

Alkalosis promotes calcium binding; the higher the amount of bound calcium, the lower the
ionized “free” active calcium

“Corrected price: 80 cents” sign:

For every 1 gram below normal albumin value (4 gm/dL), add 0.8 to the calcium level to
calculate corrected calcium or use the following equation: Corrected Calcium mg/dL =
Serum calcium + (0.8 x (4 - albumin level))

Stunned kid:

Neuromuscular irritability/tetany can result from hypocalcemia; this can include

paraesthesias, hyperreflexia, muscle spasms and seizures

Winking clown face:

Hypocalcemia can cause Chvostek’s sign which is contraction of facial muscles when the
facial nerve is tapped just in front of the ear

Hand of clown:

Trousseau’s sign is the resulting carpopedal spasm that occurs when the upper arm is
compressed in patients with hypocalcemia

Sad shop owner:

Hypocalcemia may lead to psychiatric symptoms including depression, anxiety, fatigue or

psychosis

Q u a l i T y sign:

Hypocalcemia can cause QT prolongation

Basement PthD scientist:

Hypocalcemia can occur with LOW parathyroid hormone

Scalpel door handle:

The most common cause of hypocalcemia with LOW parathyroid hormone is surgical
damage, radiation, or removal the parathyroid gland; autoimmune destruction is the second
most common cause; genetic abnormalities and infiltrative diseases are less common
causes
Door broken in antibody Y shape:

The most common cause of hypocalcemia with LOW parathyroid hormone is surgical
damage, radiation or removal the parathyroid gland; autoimmune destruction is the second
most common cause; genetic abnormalities and infiltrative diseases are less common
causes

Upstairs PthD scientist:

Hypocalcemia with HIGH parathyroid hormone aka secondary hyperparathyroidism

Lesson

Calcium Abnormalities

Hypocalcemia: Management

2/8

Video & Symbols

“Price correction: 80 cents” sign

Calculate corrected calcium: obtain albumin level, then for each 1 g/dL decrease in albumin
below 4 g/dL, add 0.8 mg/dl to calcium level

“Price correction: 80 cents” sign:

Calculate corrected calcium: obtain albumin level, then for each 1 g/dL decrease in albumin
below 4 g/dL, add 0.8 mg/dl to calcium level

Q u a l i T y sign:
Obtain EKG to rule out QT prolongation

Ice cream cup options:

Obtain ionized Ca, Mg, Phos, Vit D, PTH, albumin levels

Selfie picture:

Order imaging if applicable; in cases of osteomalacia, rickets or osteoblastic metastases

Flashing light with “Less than 75 flavors!” sign:

Urgent replacement needed if symptomatic or calcium level below 7.5mg/dL

Sweet cream topping:

IV calcium gluconate is less likely to cause tissue necrosis, and can be given via peripheral
IV so is preferred, but contains less elemental calcium (Ca gluconate 1 gram = 90mg
elemental calcium)

Salted cream topping:

IV calcium chloride carries risk of tissue necrosis if extravasation occurs but has higher
concentration of elemental Ca (Ca chloride 1 gm = 270 mg elemental calcium)

Ice cream magazine:

Replete Mg when correcting hypocalcemia

“FortifieD” carton:

Replete Vitamin D when correcting hypocalcemia related to vitamin D deficiency

Licking ice cream:

Non-emergent oral calcium and Vit D is adequate for asymptomatic or mild hypocalcemia

“Doctor’s away? Have an ice cream a day!” sign:

HypoPTH will require lifelong daily calcium and Vit D supplementation

Shriveled & P-pretzels:

CKD-related hypocalcemia may require a phosphate binder

Lesson