Mnemonic Monday: Groans and Moans… No, It's not Test Week; It's Hypercalcemia!

By Molly Lewis

In my previous mnemonic post, I taught you the “CHIMPANZEES” mnemonic for the causes of hypercalcemia, but your patient is probably not going to come to you complaining of “hyperparathyroidism.” So, what will a patient with hypercalcemia come to see you for?

  “Stones, Bones, Groans, Moans, Thrones, and Psychiatric Overtones!”

You may have heard this mnemonic before in some form, but I expanded it to include more of the most common things a patient presents with if they are hypercalcemic (plus, I included a little pathophysiology below, too, for those of you like me, who remember things better if it makes sense, versus just memorizing it).

Stones

• kidney stones
  • most kidney stones are formed of calcium phosphate or calcium oxalate
    • so more calcium can = more kidney stones!

Bones

• bone pain
  • in hyperparathyroidism, PTH (parathyroid hormone) tries to increase the blood concentration of calcium
  • what’s the biggest calcium source in your body?
    • bone!
  • so, PTH increases bone breakdown to release calcium into the blood, causing bone pain

Groans

• lethargy
• fatigue
  • I’m not 100% sure why hypercalcemia causes lethargy and fatigue, but I remember this by remembering that calcium stabilizes cell membranes.
  • If your cell membranes are too stabilized, then your body processes (muscle contraction, nerve conduction, etc) don’t happen as easily, so you get tired!
    •  or at least that’s how it works in my head…

Moans

• constipation, abdominal pain
  • the mechanism behind this is the same as what I mentioned above in “Groans”
    • muscle cell membranes that are too stabilized don’t contract as well
    • gut smooth muscle not contracting as much -> constipation!

Thrones

•  polyuria and polydipsia
  •  (throne, as in, the “porcelain throne”….a toilet!; yeah, yeah, I know… just bear with me!)
• I’ve read a few different proposed mechanisms to the pathophysiology behind this, but one example mechanism is the downregulation of aquaporin channels in the kidney’s distal tubules. This causes a nephrogenic diabetes insipidus of sorts, preventing the kidney from concentrating urine.
• unconcentrated urine -> pee a lot (polyuria) -> get thirsty -> drink a lot (polydipsia)

Psychiatric Overtones

• confusion, depression, anxiety, hallucinations, irritability, etc
  • I don’t know the mechanism behind this… If you do, post it below!

Bonus mnemonic:

A certain type of lung cancer classically presents with the above signs of hypercalcemia… Which type of cancer is it?

 “sCa++mous cell!”

That is, squamous cell!  (Yeah, the “qua” in squamous may be a far stretch from Ca++ (calcium), but I think it works!).

Squamous cell lung carcinoma can produce PTH relate peptide (PTHrp). This peptide acts like PTH, so the patient becomes hypercalcemic and presents like a patient with hyperparathyroidism. They have the “stones, bones, groans, moans, and psychiatric overtones” symptoms, with or without the other classic lung cancer symptoms (cough, hemoptysis, weight loss, shortness of breath, etc).

(Note: other cancers can make PTHrp, too, but squamous cell lung cancer is the most often tested cause).

• What if it is hard to tell whether your patient likely has hyperparathyroidism or cancer?
  • well, you can get a chest Xray and/or CT, but…
    • one clue is that primary hyperparathyroidism patients have more long-lasting, chronic symptoms, while cancer patients have more recent onset, acute symptoms.

Now that you have a good background of knowledge on the presenting symptoms of hypercalcemia, you can use the CHIMPANZEES mnemonic and the Bones, Stones, etc, mnemonic together to diagnose your patients (whether real or in a question stem!) with hypercalcemia!

Bibliography
bones, stones, etc, mnemonic from http://www.medicalmnemonics.com/cgi-bin/return_browse.cfm?discipline=Pathology&browse=1, with additions by me
hypercalcemia symptoms: https://online.epocrates.com/noFrame/showPage.do?method=diseases&MonographId=159
mechanisms behind polyuria caused by hypercalcemia
http://renalfellow.blogspot.com/2011/06/hypercalcaemia-induced-polyuria.html
bonus mnemonic: UWorld question bank