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A 67-year-old woman comes for a routine health maintenance examination. She drinks 1 ounce of alcohol daily. Her blood pressure is 138/62 mm Hg, pulse is 76/min and regular, and respirations are 14/min. The lungs are clear to auscultation. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 12.8 g/dL Serum Ca2+ 11.9 mg/dL Creatinine 0.8 mg/dL Phosphorus 2.8 mg/dL Total protein 6.5 g/dL Albumin 4.2 g/dL Ionized calcium 5.8 mg/dL (N=4.5–5.1)
Which of the following is the most appropriate next step in management?
A) Measurement of serum alkaline phosphatase activity
B) Measurement of serum parathyroid hormone level
C) Measurement of serum vitamin D level
D) Serum and urine protein electrophoresis
E) X-ray film of the chest
F) Skeletal survey
G) Bone scan
Aashi Forum Moderator
Topics: 114 Posts: 1,062
01/21/07 - 05:26 PM
#2
B) Measurement of serum parathyroid hormone level ___________________ "Obstacles are those frightful things you see when you take your EYES off your goal."
webjeee Forum Guru
Topics: 99 Posts: 354
01/28/07 - 07:36 PM
#3
won't be that easy. 67year old be ware of PTHrP from cancer how about CXR?
prathapdoctor Forum Elite
Topics: 12 Posts: 406
01/28/07 - 07:41 PM
#4
But in an asymptomatic patients without any other illness, the most common cause of hypercalcemia is hyperparathyroidism, so it would be better to measure PTH levels before doing other tests.
Adam Forum Senior
Topics: 6 Posts: 136
01/29/07 - 04:06 AM
#5
I'll go with B.
___________________ I will not say I failed 1000 times.. I will say that I discovered there are 1000 ways that can cause failure ..
MHP Forum Senior
Topics: 15 Posts: 110
01/29/07 - 07:22 AM
#6
What about the ionized ca? It is important? Why is elevated?
Mahwish Mushtaq Forum Junior
Topics: 9 Posts: 62
01/29/07 - 11:20 AM
#7
it's B
dr.wad Forum Senior
Topics: 3 Posts: 350
01/29/07 - 11:31 AM
#8
yes ( b)
MHP Forum Senior
Topics: 15 Posts: 110
01/29/07 - 11:32 AM
#9
Can anybodu¿y explain what is ionized ca? it is important here?
robin082006 Forum Hero
Topics: 471 Posts: 5,123
01/29/07 - 03:07 PM
#10
B
This is mentioned in FA
PTH first, then PTHlike peptide and others ___________________ The Key to Succeed is Patience.
prod Forum Junior
Topics: 9 Posts: 53
01/29/07 - 09:53 PM
#11
Just a query guys..why is it not choice D...serum and urine electrophoresis..67 yr old..should we consider multiple myeloma as a cause of hypercalcemia?
eaguin Forum Senior
Topics: 9 Posts: 162
03/17/07 - 02:38 PM
#12
Prod the most common cause in asymptomatic outpatients is hyperparathyroidism. He doesn't have no even ONE symptom of multiple myeloma.
fongch Forum Elite
Topics: 71 Posts: 316
04/19/07 - 05:56 PM
#13
prod wrote: Just a query guys..why is it not choice D...serum and urine electrophoresis..67 yr old..should we consider multiple myeloma as a cause of hypercalcemia?
Because the serum protein level is normal.
zaidsuror Forum Elite
Topics: 61 Posts: 238
04/20/07 - 01:51 PM
#14
i also believe it is b.The is how you should think,this is very important as a general approach,please read carefully and consider as a rule to be applied on all cases in life and vignettes in the exam. WHEN U HAVE VAUGE PRESENTATIONS ,NOT STRONGLY SUGGESTING A PARTICULAR DIAGNOSIS, GO WITH WHAT IS MOST COMMON. In this case she has assymptomatic hypercalcemia,right .THE MOST COMMON CAUSE (about 90%) OF MILD HYPERCALCEMIA IS PRIMARY HYPERTHYROIDISM.Most cases result from parathyroid adenoma ,which produces excess PTH that can be measured. so B ___________________ footsteps on the sands of time are not made by sitting around.
Justice Just signed contract
Topics: 118 Posts: 2,372
04/20/07 - 02:01 PM
#15
zaidsuror wrote: said:...WHEN U HAVE VAUGE PRESENTATIONS ,NOT STRONGLY SUGGESTING A PARTICULAR DIAGNOSIS, GO WITH WHAT IS MOST COMMON...
Strongly agree ___________________ The winner takes it all...
vradojc1 Forum Elite
Topics: 21 Posts: 309
04/20/07 - 06:21 PM
#16
Serum protein level can be within the normal range in MM. However, there is monoclonal spike that increases gamma globulins out of their range
zaidsuror Forum Elite
Topics: 61 Posts: 238
04/20/07 - 10:26 PM
#17
A SECOND RULE THAT COMPLIMENTS THE FIRST AS GENERAL APPROACHES :
Individual presentaion overules statistics and risk factors. for example if you have a vignette with all the risk factors of a coronary artery disease ,but presents woth a chest pain that is pleuretic and/or positional ,it is not MI it is pericarditis. ___________________ footsteps on the sands of time are not made by sitting around.
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