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USMLE® Step 1 questions

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USMLE® Step 1 style questions USMLE

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A 74-year-old woman is brought to the emergency department because of generalized muscle aching, weakness and pain in the left hand. The symptoms started gradually a few months ago and have been progressing over time. Past medical history is notable for uncontrolled hypertension, type 2 diabetes mellitus and end-stage renal disease. Her medications include amlodipine, hydralazine and insulin glargine. Her last recorded glomerular filtration rate is 20 mL/min, and she has been receiving dialysis three times per week for the past 2 years. A radiograph of the patient’s hands is shown below:

 Routine blood work is performed. Which of the following sets of findings will most likely be seen in this patient? 

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Hypocalcemia p. 337, 615

20q10 deletion syndromes p. 63

acute pancreatitis and p. 406

cinacalcet causing p. 364

DiGeorge syndrome p. 644

hypermagnesemia and p. 615

hyperparathyroidism p. 344

hypoparathyroidism p. 350

pseudohypoparathyroidism p. 350

renal osteodystrophy p. 628

thymic aplasia p. 114

thyroidectomy p. 349


hypocalcemia p. 615


With hypocalcemia, -hypo means below, calc- refers to calcium, and -emia refers to the blood, so hypocalcemia means lower than normal calcium levels in the blood, generally less than 8.5 mg/dL.

Now, calcium exists as an ion with a double positive charge - Ca2+ - and it’s the most abundant metal in the human body. So I know what you’re thinking - yeah, we’re all pretty much cyborgs.

Anyways, about 99% of that calcium is in our bones in the form of calcium phosphate, also called hydroxyapatite.

The last 1% is split so that the majority, about 0.99% is extracellular - which means in the blood and in the interstitial space between cells, whereas 0.01% is intracellular.

High levels of intracellular calcium causes cells to die. In fact, that’s exactly what happens during apoptosis, also known as programmed cell death. For that reason, cells end up using a ton of energy just keeping their intracellular calcium levels low.

Now, calcium gets into the cell through two types of channels, or cell doors, within the cell membrane. The first type are ligand-gated channels, which are what most cells use to let calcium in, and are primarily controlled by hormones or neurotransmitters.

The second type are voltage-gated channels, which are mostly found in muscle and nerve cells and are primarily controlled by changes in the electrical membrane potential.

So calcium flows in through these channels, and to prevent calcium levels from getting too high, cells kick excess calcium right back out with ATP-dependent calcium pumps as well as sodium calcium exchangers.

In addition, most of the intracellular calcium is stored within organelles like the mitochondria and smooth endoplasmic reticulum and is released selectively just when it's needed.

Now, the majority of the extracellular calcium, the calcium in the blood and interstitium, is split almost equally between two groups - calcium that is diffusible and calcium that is not diffusible.

Diffusible calcium is separated into two subcategories: free-ionized calcium, which is involved in all sorts of cellular processes like neuronal action potentials, contraction of skeletal, smooth, and cardiac muscle, hormone secretion, and blood coagulation, all of which are tightly regulated by enzymes and hormones.

The other category is complexed calcium, which is where the positively charged calcium is ionically linked to tiny negatively charged molecules like oxalate, which is a small anion that are normally found in our blood in small amounts. The complexed calcium forms a molecule that’s electrically neutral but unlike free-ionized calcium is not useful for cellular processes. Both of these are called diffusible because they’re small enough to diffuse across cell membranes.


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