DrVirgo
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A 40-year old asymptomatic male comes to the office for a routine physical exam. His serum chem panel shows:
Na 140
K 4.0
Bicarb 25
Cl 101
Ca 11.6
Albumin 4.0
Phosphorous 2.2
24 hour urine collection reveals a calcium level of 200mg and creatine level of 1.5g. Bone mineral density by dual energy X-ray absorptiometry (DXA) shows normal bone mineral density. Neck exam reveals no masses. What is the most appropriate next step in the management of this patient?
A. Bisphosphonate therapy
B. Surgical exploration of the neck
C. Medical surveillance
D. Loop diuretics
E. Thiazide diuretics
Whats the diagnosis/treatment? WHY?
I'll post right answer soon... this is a UW question.
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| doc_clotaire
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I would pick A
This patient most likely has primary hypeparathyroidism probably secondary to a primary adenoma ( most common cause ) . As he is ASYMPTOMATIC , I would say Bisphosphonate first
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| NE
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No convincing data support the long-term efficacy of medical therapy or simply observation in the managementof PHPT. Patients with mild HPT should be kept well hydrated. They should avoid medications such as thiazidediuretics that increase serum calcium levels. Furosemide ishelpful in well-hydrated patients.
Estrogen replacement inpostmenopausal women decreases bone resorption bydecreasing osteoclastic activity. Its role is to stabilizeBMD in those patients unable or unwilling to undergo sur-gical treatment . Bisphosphonate therapy has been shown to improve BMD in patients with PHPT without any changes in serum PTH or calcium levels Operative management is the treatmentof choice for all symptomatic patients and all asympto-matic patients younger than age 50 years or for patientswho cannot participate in adequate medical follow-up.
http://209.85.165.104/search?q=cache:rjj1GqkwsekJ...
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| snowdrops
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primary parathyroidism because of high Ca2+ and low Phosphate. Need check parathyroid for next step. Because Ca2+ is not above 15, which need reduce it immediately, so medication is not urgent. So, the answer is B.
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| Geroo
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answer B
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| mytime
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C.
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| DrVirgo
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The right answer is B.
The following is not my opinion, but the given explanation, so please don't kill me for it: 
Surgical intervention (parathyroidectomy) is needed for all patients with SYMPTOMATIC PRIMARY HYPERTHYROIDISM. Not all asymptomatic patients require such treatment. The indication for surgery in an ASYMPTOMATIC patient is the presence of at lease ONE of the following:
1. Serum Ca at least 1 mg/dL above the upper norm limit with urinary Ca excretion greater than 50 mg/24hr
2. Urinary calcium excretion greater than 400mg/24 hr
3. Young patients (<50 years old)
4. Bone mineral density lower than T- 2.5 at any site
5. Difficulty in follow-up of the patient.
A and D: Bisphosphonate and Loops are used for the treatment of SYMPTOMATIC HYPERCALCEMIA.
So, what do for a patient with Symptomatic Primary HYPER-PTH which presents with increased Calcium? Surgery or bisphosphonates???
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| mytime
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Geroo got it!  
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| DrVirgo
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Yeah, about 19% of the people got this one right... I say they guessed! haha...
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| DrVirgo
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I'm still confused about this... can anyone help me out?
We know:
1. Surgical intervention (parathyroidectomy) is needed for all patients with SYMPTOMATIC PRIMARY HYPERTHYROIDISM.
and
2. Bisphosphonate and Loops are used for the treatment of SYMPTOMATIC HYPERCALCEMIA.
So, what is the treatment for a patient with Symptomatic Primary HYPER-PTH which presents with increased Calcium? Surgery or bisphosphonates???
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