Autoimmune polyendocrine syndrome physical examination: Difference between revisions

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__NOTOC__
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{{Autoimmune polyendocrine syndrome}}
{{Autoimmune polyendocrine syndrome}}
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}}{{Akshun}}


==Overview==
==Overview==
The physical examination findings in autoimmune polyendocrine syndrome (APS)  may include [[hypotension]], [[bradycardia]], [[tetany]], dry [[skin]], coarse [[hair]],  and [[muscle]] weakness depending upon the sub-type and the organ affected such as [[Adrenal Gland|adrenals]], [[thyroid]] or [[Pancreatic islets|pancreatic islet cells]]. Patients of APS usually appear [[Fatigue|fatigued]] and [[dehydrated]].


==Physical Examination==
==Physical Examination==
*The physical examination in autoimmune polyendocrine syndrome is variable and depends upon the subtype and the involved organ.  
*The [[physical examination]] in autoimmune polyendocrine syndrome is variable and depends upon the sub-type and the organ involved.  
*APS can involve a number of organs and the most common conditions associated with APS are described below.
*APS can involve multiple organs and the most common conditions associated with APS such as [[Addison's disease]], [[type 1 diabetes mellitus]] and [[hypoparathyroidism]] are described below.
===Addisons's disease===
===Addisons's disease===
'''Appearance''
The patient may be [[dehydrated]] and [[lethargic]].<ref name="pmid23633816">{{cite journal |vauthors=Sarkar SB, Sarkar S, Ghosh S, Bandyopadhyay S |title=Addison's disease |journal=Contemp Clin Dent |volume=3 |issue=4 |pages=484–6 |year=2012 |pmid=23633816 |pmc=3636818 |doi=10.4103/0976-237X.107450 |url=}}</ref>
The patient may be [[dehydrated]] and [[lethargic]].<ref name="pmid23633816">{{cite journal |vauthors=Sarkar SB, Sarkar S, Ghosh S, Bandyopadhyay S |title=Addison's disease |journal=Contemp Clin Dent |volume=3 |issue=4 |pages=484–6 |year=2012 |pmid=23633816 |pmc=3636818 |doi=10.4103/0976-237X.107450 |url=}}</ref>


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* [[Fever]]
* [[Fever]]


''Skin''
'''Skin'''
* Pigmented skin and mucous membranes - darkening ([[hyperpigmentation]]) of the skin, including areas not exposed to the sun; characteristic sites are skin creases (e.g. of the hands), nipples, and the inside of the cheek (buccal mucosa), also old scars may darken.
* [[Hyperpigmentation|Hyperpigmented]] [[skin]] and [[mucous membranes]] - darkening ([[hyperpigmentation]]) of the [[skin]], including areas not exposed to the sun; characteristic sites are [[skin]] creases (e.g. of the hands), nipples, and the inside of the cheek ([[buccal]] [[Mucosal|mucosa]]), old scars may also darken.
* [[Vitiligo]] may be present.
* [[Vitiligo]] may be present.
* Absence of axillary and pubic hair in females as a result of loss of adrenal [[androgens]].
* Absence of [[axillary]] and [[pubic]] hair in [[females]] as a result of loss of [[adrenal]] [[androgens]].
* [[Pallor]] may be present.
* [[Pallor]] may be present.


''Neck''
'''Neck'''
* [[Goiter]] may be present.
* [[Goiter]] may be present.


''Extremities''
'''Extremities'''
* [[Weakness]]
* [[Weakness]]


''Neurologic''
'''Neurologic'''
* [[Confusion]] may be present
* [[Confusion]] may be present
* [[Seizures]] may be present.
* [[Seizures]] may be present.


===Type 1 diabetes mellitus===
===Type 1 diabetes mellitus===
Physical examination of type 1 DM include:<ref>http://www.aafp.org/afp/2005/0501/p1705.pdf</ref><ref>Type 1 Diabetes mellitus "Dennis Kasper, Anthony Fauci, Stephen Hauser, Dan Longo, J. Larry Jameson, Joseph Loscalzo"Harrison's Principles of Internal Medicine, 19e Accessed on December 27th,2016</ref><ref>http://spectrum.diabetesjournals.org/content/15/1/28</ref><ref>{{Cite web|url=http://care.diabetesjournals.org/content/26/suppl_1/s109|title=ADA|last=|first=|date=|website=|publisher=|access-date=}}</ref>
[[Physical examination]] of type 1 DM include:<ref>http://www.aafp.org/afp/2005/0501/p1705.pdf</ref><ref>Type 1 Diabetes mellitus "Dennis Kasper, Anthony Fauci, Stephen Hauser, Dan Longo, J. Larry Jameson, Joseph Loscalzo"Harrison's Principles of Internal Medicine, 19e Accessed on December 27th,2016</ref><ref>http://spectrum.diabetesjournals.org/content/15/1/28</ref><ref>{{Cite web|url=http://care.diabetesjournals.org/content/26/suppl_1/s109|title=ADA|last=|first=|date=|website=|publisher=|access-date=}}</ref>
{| class="wikitable"
{| class="wikitable"
!Examination findings  
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Examination findings  
!Classic new onset  
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Classic new onset  
!Diabetic ketoacidosis  
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Diabetic ketoacidosis  
|-
|-
|Appearance of patient  
|'''Appearance of patient'''
|Patient is usually well appearing  
|Patient is usually well appearing  
|Patients are ill appearing, may be confused or in state of [[coma]]
|Patients are ill appearing, may be confused or in state of [[coma]]
|-
|-
|Vital Signs
|'''[[Vital signs]]'''
|[[Pulse rate]]- Normal  
|[[Pulse rate]]- Normal  
[[Temperature]]- Normal  
[[Temperature]]- Normal  
Line 55: Line 55:


[[Blood glucose]] level- Elevated
[[Blood glucose]] level- Elevated
|Pulse rate- [[Tachycardia]] with regular rhythm, weak volume
|[[Pulse rate]]- [[Tachycardia]] with regular rhythm, weak volume
Temperature- Normal or elevated or [[hypothermia]]  
Temperature- Normal or elevated or [[hypothermia]]  


Blood pressure- Low blood pressure  
[[Blood pressure]]- Low [[blood pressure]]


Respiratory rate-  
[[Respiratory rate]]-  
* [[Tachypnea]]  
* [[Tachypnea]]  
* Kussmal respirations may be present in late presentation  
* [[Kussmaul respirations]] may be present in case of late presentation  
[[Oxygen saturation]]- usually normal but some cases may have low oxygen saturation.  
[[Oxygen saturation]]- usually normal but some cases may have low [[oxygen saturation]]  


Blood glucose level- markedly elevated  
[[Blood glucose]] level- markedly elevated  


|-
|-
|[[Skin]]
|[[Skin|'''Skin''']]
|Skin examination is usually normal, but in some cases may reveal dry skin
|[[Skin]] examination is usually normal, but in some cases may reveal dry [[skin]]
|Poor skin turgor because of dehydration  
|Poor [[skin]] [[turgor]] because of [[dehydration]]
|-
|-
|HEENT
|'''HEENT'''
|HEENT examination is usually normal, in some cases eye examination may reveal opacity of lens(Cataract)
|HEENT examination is usually normal, in some cases [[eye]] examination may reveal opacity of [[lens]] ([[cataract]])
|Dry mucous membrane, eyes may appear sunken because of dehydration  
|Dry [[mucous membrane]], [[eyes]] may appear sunken because of [[dehydration]]
|-
|-
|Neck
|'''Neck'''
|Neck examination is  normal
|[[Neck]] examination is  normal
|Neck examination is normal  
|[[Neck]] examination is normal  
|-
|-
|[[Lungs]]
|[[Lungs|'''Lungs''']]
|Lungs examination is normal
|[[Lung]] examination is normal
|Lungs examination is usually normal, but in some cases lung examination may reveal underlying triggering causes of diabetes ketoacidosis eg: [[pneumonia]]
|[[Lung]] examination is usually normal, but in some cases [[lung]] examination may reveal underlying triggering causes of [[diabetic ketoacidosis]] eg: [[pneumonia]]
|-
|-
|[[Heart]]  
|[[Heart|'''Heart''']]  
|Heart examination is normal
|[[Heart]] examination is normal (S1 + S2 + 0)
|Heart examination is usually normal  
|[[Heart]] examination is usually normal (S1 + S2 + 0)
|-
|-
|[[Abdomen]]  
|[[Abdomen|'''Abdomen''']]  
|Abdominal examination is normal
|[[Abdominal]] examination is normal
|Abdominal tenderness may be elicited  
|[[Abdominal]] [[tenderness]] may be elicited  
|-
|-
|Back
|'''Back'''
|Back examination is normal
|Back examination is normal
|Back examination is usually normal
|Back examination is usually normal
|-
|-
|[[Genitourinary]]
|[[Genitourinary|'''Genitourinary''']]
|Genitourinary examination is usually normal
|[[Genitourinary]] examination is usually normal
|Genitourinary examination is usually normal
|[[Genitourinary]] examination is usually normal
|-
|-
|[[Extremities]]  
|[[Extremities|'''Extremities''']]  
|Extremities examination is usually normal, some cases may elicit finding of decreased sensation in the extremities
|Examination of [[extremities]] is usually normal, some cases may elicit finding of decreased sensation in the [[extremities]]
|Extremities examination is usually normal
|Examination of [[extremities]] is usually normal
|-
|-
|[[Neuromuscular]]  
|[[Neuromuscular|'''Neuromuscular''']]  
|Neuromuscular examination is usually normal,
|[[Neuromuscular]] examination is usually normal  
|Neuromuscular examination is usually normal  
|[[Neuromuscular]] examination is usually normal  
|}
|}


===Hypoparthyroidism===
===Hypoparthyroidism===
*Physical examination of patients with hypoparathyroidism is usually due to [[hypocalcemia]].<ref name="pmid28138323">{{cite journal |vauthors=Abate EG, Clarke BL |title=Review of Hypoparathyroidism |journal=Front Endocrinol (Lausanne) |volume=7 |issue= |pages=172 |year=2016 |pmid=28138323 |pmc=5237638 |doi=10.3389/fendo.2016.00172 |url=}}</ref><ref name="pmid18535072">{{cite journal |vauthors=Cooper MS, Gittoes NJ |title=Diagnosis and management of hypocalcaemia |journal=BMJ |volume=336 |issue=7656 |pages=1298–302 |year=2008 |pmid=18535072 |pmc=2413335 |doi=10.1136/bmj.39582.589433.BE |url=}}</ref>
*[[Physical examination]] of patients with [[hypoparathyroidism]] is usually due to [[hypocalcemia]].<ref name="pmid28138323">{{cite journal |vauthors=Abate EG, Clarke BL |title=Review of Hypoparathyroidism |journal=Front Endocrinol (Lausanne) |volume=7 |issue= |pages=172 |year=2016 |pmid=28138323 |pmc=5237638 |doi=10.3389/fendo.2016.00172 |url=}}</ref><ref name="pmid18535072">{{cite journal |vauthors=Cooper MS, Gittoes NJ |title=Diagnosis and management of hypocalcaemia |journal=BMJ |volume=336 |issue=7656 |pages=1298–302 |year=2008 |pmid=18535072 |pmc=2413335 |doi=10.1136/bmj.39582.589433.BE |url=}}</ref>
*The presence of [[tetany]] on physical examination is diagnostic of [[hypocalcemia]] which is commonly caused by hypoparathyroidism.<ref>{{cite book |last1=Schafer |first1=AL |last2=Shoback |first2=DM |editor-last1=De Groot |editor-first1=LJ |editor-last2=Chrousos |editor-first2=G |editor-last3=Dungan |editor-first3=K  |display-editors=etal |date= |title=Hypocalcemia: Diagnosis and Treatment. [Updated 2016 Jan 3]. |url=https://www.ncbi.nlm.nih.gov/books/NBK279022/ |location= Endotext [Internet]. |publisher=South Dartmouth (MA): MDText.com, Inc.; 2000-. |page= |isbn= |author-link= }}</ref>
*The presence of [[tetany]] on [[physical examination]] is diagnostic of [[hypocalcemia]] which is commonly caused by [[hypoparathyroidism]].<ref>{{cite book |last1=Schafer |first1=AL |last2=Shoback |first2=DM |editor-last1=De Groot |editor-first1=LJ |editor-last2=Chrousos |editor-first2=G |editor-last3=Dungan |editor-first3=K  |display-editors=etal |date= |title=Hypocalcemia: Diagnosis and Treatment. [Updated 2016 Jan 3]. |url=https://www.ncbi.nlm.nih.gov/books/NBK279022/ |location= Endotext [Internet]. |publisher=South Dartmouth (MA): MDText.com, Inc.; 2000-. |page= |isbn= |author-link= }}</ref>
*The presence of [[Chvostek's sign]] and [[Trousseau's sign|Trousseau's sign]] on physical examination is highly suggestive of [[hypocalcemia]] which is commonly caused by hypoparathyroidism.<ref name="pmid18650515">{{cite journal |vauthors=Shoback D |title=Clinical practice. Hypoparathyroidism |journal=N. Engl. J. Med. |volume=359 |issue=4 |pages=391–403 |year=2008 |pmid=18650515 |doi=10.1056/NEJMcp0803050 |url=}}</ref>
*The presence of [[Chvostek's sign]] and [[Trousseau's sign|Trousseau's sign]] on [[physical examination]] is highly suggestive of [[hypocalcemia]] which is commonly caused by [[hypoparathyroidism]].<ref name="pmid18650515">{{cite journal |vauthors=Shoback D |title=Clinical practice. Hypoparathyroidism |journal=N. Engl. J. Med. |volume=359 |issue=4 |pages=391–403 |year=2008 |pmid=18650515 |doi=10.1056/NEJMcp0803050 |url=}}</ref>


''Appearance of the Patient''
'''Appearance of the Patient:'''
*Patients with hypoparathyroidism usually have [[neuromuscular]] [[irritability]] and may appear [[dysphoric]].
*Patients with [[hypoparathyroidism]] usually have [[neuromuscular]] [[irritability]] and may appear [[dysphoric]].


''Vital Signs''
'''Vital Signs:'''
Some patient may have:
*[[Bradycardia]]
*[[Bradycardia]]


''Skin''
'''Skin:'''
Careful examination of [[skin]] around [[neck]] should be done for [[surgical]] scar.
 
Careful examination of [[skin]] around [[neck]] should be done for a possible [[surgical]] scar.


Common signs present are:
Common signs present are:
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*Coarse [[hair]]
*Coarse [[hair]]


''HEENT''
'''HEENT:'''
 
Some patients may have:
Some patients may have:
*Subcapsular [[cataracts]]
*Subcapsular [[cataracts]]
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''Lungs''
'''Lungs:'''
 
Some patients may have:
Some patients may have:
*[[Dyspnea]]
*[[Dyspnea]]
*[[Wheeze|Wheezing]]
*[[Wheeze|Wheezing]]


''Heart'''
'''Heart:'''
 
Some patients may have:
Some patients may have:
*[[Palpitation]]
*[[Palpitation]]
Line 146: Line 149:
* Signs of [[cardiomyopathy]]<ref name="pmid1633370">{{cite journal |vauthors=Kudoh C, Tanaka S, Marusaki S, Takahashi N, Miyazaki Y, Yoshioka N, Hayashi M, Shimamoto K, Kikuchi K, Iimura O |title=Hypocalcemic cardiomyopathy in a patient with idiopathic hypoparathyroidism |journal=Intern. Med. |volume=31 |issue=4 |pages=561–8 |year=1992 |pmid=1633370 |doi= |url=}}</ref>
* Signs of [[cardiomyopathy]]<ref name="pmid1633370">{{cite journal |vauthors=Kudoh C, Tanaka S, Marusaki S, Takahashi N, Miyazaki Y, Yoshioka N, Hayashi M, Shimamoto K, Kikuchi K, Iimura O |title=Hypocalcemic cardiomyopathy in a patient with idiopathic hypoparathyroidism |journal=Intern. Med. |volume=31 |issue=4 |pages=561–8 |year=1992 |pmid=1633370 |doi= |url=}}</ref>


''Abdomen''
'''Abdomen:'''
 
Some patients may have:
Some patients may have:
* [[Dysphagia]]
* [[Dysphagia]]


''Neuromuscular''
'''Neuromuscular:'''
Most common presentation is due to neuromuscular irritability. It present as:
 
Most common presentation is due to [[neuromuscular]] irritability. It present as:
*[[Tetany|Tetany]]
*[[Tetany|Tetany]]
*[[Chvostek's sign]]: [[Facial twitching]], especially around the [[mouth]]. It is elicited by tapping the [[cheek]] (2 cm anterior to the earlobe below the [[zygomatic process]]) over the path of the [[facial nerve]]. Ipsilateral [[twitching]] of the upper [[lip]] is considered as positive sign.
*[[Chvostek's sign]]: [[Facial]] twitching, especially around the [[mouth]]. It is elicited by tapping the [[cheek]] (2 cm anterior to the earlobe below the [[zygomatic process]]) over the path of the [[facial nerve]]. Ipsilateral [[twitching]] of the upper [[lip]] is considered as positive sign.
*[[Trousseau's sign]]: Painful carpal spasm. It is elicited by inflating a [[blood pressure]] cuff around the arm to a pressure 20 mm Hg above obliteration of the [[radial pulse]] for 3-5 minutes.
*[[Trousseau's sign]]: Painful [[carpal]] [[spasm]]. It is elicited by inflating a [[blood pressure]] cuff around the arm to a pressure 20 mm Hg above obliteration of the [[Radial artery|radial]] [[pulse]] for 3-5 minutes.
*[[Tingling]], burning, and/or [[numbness]] in the [[Fingertip|fingertips]], [[Toe|toes]] and [[lips]]
*[[Tingling]], burning, and/or [[numbness]] in the [[Fingertip|fingertips]], [[Toe|toes]] and [[lips]]
*[[Muscle weakness]]
*[[Muscle weakness]]
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*[[Hemiballismus]]
*[[Hemiballismus]]


''Psychiatric''
'''Psychiatric:'''
Some patients may have psychiatric manifestations:<ref name="pmid11834431">{{cite journal |vauthors=Arlt W, Fremerey C, Callies F, Reincke M, Schneider P, Timmermann W, Allolio B |title=Well-being, mood and calcium homeostasis in patients with hypoparathyroidism receiving standard treatment with calcium and vitamin D |journal=Eur. J. Endocrinol. |volume=146 |issue=2 |pages=215–22 |year=2002 |pmid=11834431 |doi= |url=}}</ref><ref name="pmid25772947">{{cite journal |vauthors=Lin KF, Chen KH, Huang WL |title=Organic anxiety in a woman with breast cancer receiving denosumab |journal=Gen Hosp Psychiatry |volume=37 |issue=2 |pages=192.e7–8 |year=2015 |pmid=25772947 |doi=10.1016/j.genhosppsych.2015.01.007 |url=}}</ref>
 
Some patients may have [[psychiatric]] manifestations:<ref name="pmid11834431">{{cite journal |vauthors=Arlt W, Fremerey C, Callies F, Reincke M, Schneider P, Timmermann W, Allolio B |title=Well-being, mood and calcium homeostasis in patients with hypoparathyroidism receiving standard treatment with calcium and vitamin D |journal=Eur. J. Endocrinol. |volume=146 |issue=2 |pages=215–22 |year=2002 |pmid=11834431 |doi= |url=}}</ref><ref name="pmid25772947">{{cite journal |vauthors=Lin KF, Chen KH, Huang WL |title=Organic anxiety in a woman with breast cancer receiving denosumab |journal=Gen Hosp Psychiatry |volume=37 |issue=2 |pages=192.e7–8 |year=2015 |pmid=25772947 |doi=10.1016/j.genhosppsych.2015.01.007 |url=}}</ref>
*[[Anxiety]]
*[[Anxiety]]
*[[Depression]]
*[[Depression]]
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*[[Anxiety]]
*[[Anxiety]]


''Extremities''
'''Extremities:'''
 
Some patients may have:
Some patients may have:
*Edema due to cardiac dysfunction
*[[Edema]] due to [[cardiac]] dysfunction


==References==
==References==

Latest revision as of 14:43, 30 October 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akshun Kalia M.B.B.S.[2]

Overview

The physical examination findings in autoimmune polyendocrine syndrome (APS) may include hypotension, bradycardia, tetany, dry skin, coarse hair, and muscle weakness depending upon the sub-type and the organ affected such as adrenals, thyroid or pancreatic islet cells. Patients of APS usually appear fatigued and dehydrated.

Physical Examination

Addisons's disease

The patient may be dehydrated and lethargic.[1]

Vitals

Skin

Neck

Extremities

Neurologic

Type 1 diabetes mellitus

Physical examination of type 1 DM include:[2][3][4][5]

Examination findings Classic new onset Diabetic ketoacidosis
Appearance of patient Patient is usually well appearing Patients are ill appearing, may be confused or in state of coma
Vital signs Pulse rate- Normal

Temperature- Normal

Blood pressure- Normal

Respiratory rate- Normal

Oxygen saturation- Normal

Blood glucose level- Elevated

Pulse rate- Tachycardia with regular rhythm, weak volume

Temperature- Normal or elevated or hypothermia

Blood pressure- Low blood pressure

Respiratory rate-

Oxygen saturation- usually normal but some cases may have low oxygen saturation

Blood glucose level- markedly elevated

Skin Skin examination is usually normal, but in some cases may reveal dry skin Poor skin turgor because of dehydration
HEENT HEENT examination is usually normal, in some cases eye examination may reveal opacity of lens (cataract) Dry mucous membrane, eyes may appear sunken because of dehydration
Neck Neck examination is normal Neck examination is normal
Lungs Lung examination is normal Lung examination is usually normal, but in some cases lung examination may reveal underlying triggering causes of diabetic ketoacidosis eg: pneumonia
Heart Heart examination is normal (S1 + S2 + 0) Heart examination is usually normal (S1 + S2 + 0)
Abdomen Abdominal examination is normal Abdominal tenderness may be elicited
Back Back examination is normal Back examination is usually normal
Genitourinary Genitourinary examination is usually normal Genitourinary examination is usually normal
Extremities Examination of extremities is usually normal, some cases may elicit finding of decreased sensation in the extremities Examination of extremities is usually normal
Neuromuscular Neuromuscular examination is usually normal Neuromuscular examination is usually normal

Hypoparthyroidism

Appearance of the Patient:

Vital Signs:

Skin:

Careful examination of skin around neck should be done for a possible surgical scar.

Common signs present are:

HEENT:

Some patients may have:


Lungs:

Some patients may have:

Heart:

Some patients may have:

Abdomen:

Some patients may have:

Neuromuscular:

Most common presentation is due to neuromuscular irritability. It present as:

Some patients may have extrapyramidal signs (due to calcification of basal ganglia):[13]

Psychiatric:

Some patients may have psychiatric manifestations:[14][15]

Extremities:

Some patients may have:

References

  1. ↑ Sarkar SB, Sarkar S, Ghosh S, Bandyopadhyay S (2012). "Addison's disease". Contemp Clin Dent. 3 (4): 484–6. doi:10.4103/0976-237X.107450. PMC 3636818. PMID 23633816.
  2. ↑ http://www.aafp.org/afp/2005/0501/p1705.pdf
  3. ↑ Type 1 Diabetes mellitus "Dennis Kasper, Anthony Fauci, Stephen Hauser, Dan Longo, J. Larry Jameson, Joseph Loscalzo"Harrison's Principles of Internal Medicine, 19e Accessed on December 27th,2016
  4. ↑ http://spectrum.diabetesjournals.org/content/15/1/28
  5. ↑ "ADA".
  6. ↑ Abate EG, Clarke BL (2016). "Review of Hypoparathyroidism". Front Endocrinol (Lausanne). 7: 172. doi:10.3389/fendo.2016.00172. PMC 5237638. PMID 28138323.
  7. ↑ Cooper MS, Gittoes NJ (2008). "Diagnosis and management of hypocalcaemia". BMJ. 336 (7656): 1298–302. doi:10.1136/bmj.39582.589433.BE. PMC 2413335. PMID 18535072.
  8. ↑ Schafer, AL; Shoback, DM. De Groot, LJ; Chrousos, G; Dungan, K; et al., eds. Hypocalcemia: Diagnosis and Treatment. [Updated 2016 Jan 3]. Endotext [Internet].: South Dartmouth (MA): MDText.com, Inc.; 2000-.
  9. ↑ Shoback D (2008). "Clinical practice. Hypoparathyroidism". N. Engl. J. Med. 359 (4): 391–403. doi:10.1056/NEJMcp0803050. PMID 18650515.
  10. ↑ Sheldon RS, Becker WJ, Hanley DA, Culver RL (1987). "Hypoparathyroidism and pseudotumor cerebri: an infrequent clinical association". Can J Neurol Sci. 14 (4): 622–5. PMID 3690435.
  11. ↑ Levine SN, Rheams CN (1985). "Hypocalcemic heart failure". Am. J. Med. 78 (6 Pt 1): 1033–5. PMID 4014262.
  12. ↑ Kudoh C, Tanaka S, Marusaki S, Takahashi N, Miyazaki Y, Yoshioka N, Hayashi M, Shimamoto K, Kikuchi K, Iimura O (1992). "Hypocalcemic cardiomyopathy in a patient with idiopathic hypoparathyroidism". Intern. Med. 31 (4): 561–8. PMID 1633370.
  13. ↑ Basak RC (2009). "A case report of Basal Ganglia calcification - a rare finding of hypoparathyroidism". Oman Med J. 24 (3): 220–2. doi:10.5001/omj.2009.44. PMC 3251182. PMID 22224190.
  14. ↑ Arlt W, Fremerey C, Callies F, Reincke M, Schneider P, Timmermann W, Allolio B (2002). "Well-being, mood and calcium homeostasis in patients with hypoparathyroidism receiving standard treatment with calcium and vitamin D". Eur. J. Endocrinol. 146 (2): 215–22. PMID 11834431.
  15. ↑ Lin KF, Chen KH, Huang WL (2015). "Organic anxiety in a woman with breast cancer receiving denosumab". Gen Hosp Psychiatry. 37 (2): 192.e7–8. doi:10.1016/j.genhosppsych.2015.01.007. PMID 25772947.

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