Calcium Dysregulation

Chronic- at least 5 years

Severe- previous office visits for same CC

Tried stool softeners, high fiber supplements

Needs laxatives for 1x/wk bowel movement

HTN

Metoproplol

Tobacco use

Routine health: up-to-date

PE: unremarkable

HTN- both parents

Colonoscopy: normal

Kidney function: normal

TSH: normal

Calcium levels: trending up

TSH: normal

Electrolytes: normal

Calcium level: high (11.2mg/dL)

Indications

Stable, symptomatic

Calcium >11.0

Calcium >1mg/dL above normal

Diagnosed at <50yo.

Surgical exploration with partial parathyroidectomy

Complications

injury to recurrent laryngeal nerve(s)

hypoparathyroidism

chronic hypocalcemia requiring life-long calcium and vitamin D supplemention

General treatment and eduction

increase water intake and exercise

Avoid thiazides, large doses of Vit D, calcium, or immboilization

long term monitoring: serum calcium, iPTH, DEXA

Primary Hyperparathyroidism

Questions

Last menstrual period?

Previous DEXA scan?

N/V?

Change in mood?

Change in energy levels?

Usual PE findings

Mild bone pain

Proximal weakness

Myalgia

Decreased DTR

Abdominal pain

Palpitations

Additional labs

Repeat Calcium

Hypercalcemia

PTH

High

Acute duration- Primary hyperparathyroid

Chronic duration- Parathyroidism

X-ray/DEXA

usual normal

may show show dec bone density, brown tumor

PUD

Pre-op sestamibi-iodine subtraction scanning and ultrasound of neck

iPTH

increase

Urinary Calcium and PO4

increased

Serum PO4

decreased

25 (OH) vitamin D

low +/-

Cr/BUN, 24hr urine for Ca and Cr

rule out other etiologies

EKG

tall, peaked T waves, short QT interval

heart block, bradyarrythmia

Secondary Hyperparathyroidism

Questions

New aches for pains?

Recent kidney issues, such as kidney stones?

PE

Bone/joint pain

Abdominal pain from nephrolithiosis

Labs for CKD/malabsorption

serum Ca

hypocalcemia

PTH

increased

iPTH

increase

serum PO4

increase

blood work

anemia

alk phophs

inc +/-

25 (OH) vit D

normal

dec in surgical malabsorption

1,25 dihydroxy vit D

dec

Hypercalcemia of malignancy- Metastatic tumor

Questions

PMHx or FHx of cancer?

Usual PE findings

Non-tender, firm, immobile mass

Additional labs

Ultrasound

thyroid metastatic tumor

PTHrP assay

inc PTHrP, dec iPTH

Mammogram

Breast metastatic tumor

CT/MRI

pancreas metastatic tumor

CBC w diff

leukemia, multiple myeloma

X-ray

SCC lung metastatic tumor

Multiple Endocrine Neoplasm

Questions

FHx of MEN?

PE

pain with abdominal palpation

gastrinoma

weight loss

glucagonoma

bone abnormalities, pain

weakness

Labs

Genetic testing

mutation in Menin gene

PTH

increase

Gastrin, insulin, glucagon, somatostatin levels

all possibly increases

Prolactin

increase

Granulomatous Disease

Sarcoidosis, TB

Questions

Hx of TB

Increased thirst?

PE

infiltrative lesion

Labs

1,25-dihydroxyvitaminD- inc

PTH- low

PTHrP- now elevated

Drugs

Questions

Taking any other medications in addition to Metropolol?

Li, Antacids, Thiazide diuretic, Vit D. intoxication

PE findings

N/V

bone pain

abdominal pain

Labs

PTH- low

PTHrP- not elevated

1,25-dihydroxyvitaminD- not elevated

25-hydroxyvitamin D- inc

Acute Renal Failure

Questions

recent change in urine output?

recent fatigue?

recent hospitalization?

PE

edema

nausea

shortness of breath

Labs

PTH- low

electrolytes- abnormal

Adrenal insufficiency/thryotoxicosis

Questions

increased irritability?

heat intolerance?

palpitations?

Fatigue or weakness?

weight loss with increased appetite?

Subtopic

PE

tachycardia

tremor

goiter

moist skin

muscle weakness

lid retraction/lag

Labs

PTH- low

free T4- inc

TSH- low