<<forEachTiddler  where 'tiddler.tags.contains(context.inTiddler.title)'
sortBy 
        tiddler.title
    ascending 
write '"*[["+tiddler.title+"]]\n"'>>
<<tiddler AutoRefresh with: force>>

severe >3.5 - emergency which needs admission  (moderate 2.88-3.5)
Sx - n/v, constipation, depression, myalgia, arthralgia, lethargy, polyuria, polydipsia - in early aSx phase
else - stones, bones, abdo groans and moans
complications - osteoporotic fracture, renal colic, CVS - arrythmia, HT, pancreatitis
check PTH, PO3 (low/N), alk phos (high)

''Causes'' - 80% malignancy or hyperparathyroidism
Drugs - thiazides (dec renal tubular excretion Ca) and lithium, xs vit D supplement, Ca containing antacids
Malignancy but unlikely in well pt (Bone mets, myeloma. PTHrP from sq lung)
Primary hyperparathyroidism - 2% postmen women
Sarcoid, (TB (both granulomatous) and histoplasmosis
Acute adrenal failure
Thyrotoxicosis - inc osteoclast activity
Familial hypocalciuric hypercalcaemia - reduced renal excretion
renal transplant - tertiary hyperparathyroidism
Vitamin D intoxication
Acromegaly
Milk alkali syndrome
Dehydration 
Addisons
Pagets disease of bone (Ca usually N but may be high if prolonged immobilisation)


''Primary hyperparathyroidism''
80% single adenoma
15-20% multinodular hyperplasia
rare - carcinoma
10% are familial - (MEN1and 2, jaw tumour syndrome)
Ix (2ndary) - bone density scan, renal function, 24hr urine Ca, USS for renal stones, ECG for HT changes
Mx - surgery if Sx or if <50yr, hypercalciuria, dec eGFR, cortical bone loss
osteoporosis changes may not be resolved with surgery
 
''Hypercalcaemia and malignancy''
may be due to bony mets but also due to PTH-like peptides released by many tumours (esp lung, breast, kidney, head/neck - prostate less so as osteoblastic) and dec renal loss
poor prognostic indicator
need to rehydrate with Nsaline then bisphosphonates (IV for rapid action) - 
dehydration is viscious cycle with it causing polyuria which inc the hyperCa.
need to check PTH as may be primary hyperparathyroid so treatable

''Multiple Myeloma''
High total protein, low albumin
Anaemia, renal impairment and rouleaux
low immunity (persistent infections)
Hypercalcaemia - due to tumour induced local bone destruction
 
''Pseudohyperparathyroidism'' - abnormal albumin / protein levels
tourniquet on too long - due to cell lysis - repeat fasting without tourniquet