A ۲۲ y/o Female presented to the emergency department complaining of back pain

Introduction:Hypocalcemia can have many causes and presents with a variety of manifestations such as muscle cramps, tetany, paresthesia, numbness and even seizure. Parathyroid insufficiency as a cause of hypocalcemia is relative common after thyroidectomy; therefore, a careful history taking is very important in identifying the problem and the cause. Purpose: A simple back pain with a special attention to the patient’s history can lead to a diagnosis of a serious problem like hypocalcemia.Case report:A ۲۲ y/o Female presented to the ED complaining of back pain since the previous night. The back pain was dull and not localized to any particular area. She also complained of nausea (no vomiting), neck pain and headache. She had similar back pain intermittently for months, but it was worse that day. She also had photophobia, subjective fevers and generalized weakness. She denied dysuria, frequency, urgency, hematuria, visual changes or focal weakness or numbness. Past medical history was negative except for "neck surgery" for cancer, which she had several months ago. She did not drink or smoke. Her vital signs were within the normal range. Generally, she was a flushed uncomfortable female appearing moderately ill. Funduscopic examination was normal. Her neck was supple, with a well-healed thyroidectomy scar. Examining extremities revealed some back pain with straight leg raise on the left, full pulses and no evidence of arthropathy. Neurologic examination revealed normal mental state, fluent Speak, intact cranial nerves and normal motor examination. Also, Laboratory data revealed WBC: ۵.۲, Hgb: ۱۲.۳, Plt: ۱۹۸, Na: ۱۴۰, glc: ۸۶, K: ۳.۵ and Cr: ۰.۷. CXR and lumbosacral CT scan were normal. CSF examination showed no WBCs, no RBCs, protein: ۱۱ and glucose: ۵۷. The patient received IV ketorolac with good relief of her back pain. She fell asleep, but was easily arousable, while awaiting her lab test results. While she was sleeping, her BP was noted to fall to ۷۱/۳۹, with a HR of ۵۸. The patient was awakened at that time and felt fine; IV Fluid were administered. A repeat BP was ۷۴/۴۲ with a HR of ۶۲. Finally, the patient's calcium level was ۴.۹ and She has hypocalcemia secondary to hypoparathyroidism. Also on ECG, widening of all intervals was obvious. Her hypocalcemia was treated and gradually she felt better and her symptoms were gone.Conclusion:There were ۳ clues to this diagnosis. First of all, she was postoperative from thyroid surgery, and parathyroid insufficiency is a fairly common complication of thyroid surgery. She had symptoms of malaise and abdominal complaints and her cardiogram showed widening of all of the intervals.