bill
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Q) A 68-year-old woman with a 2-year-history of asymptomatic hyperparathyroidism reports generalized anxiety and intermittent confusion. She wears a pacemaker for sick sinus syndrome and is otherwise healthy. Evaluation, 6 months ago, showed normal results on serum and urine protein electrophoresis, mammography, radiography of the chest, and USG of the neck. The immunoreactive PTH level was 5 times the normal level and the ionized serum calcium level was increased. Presently, she has a serum calcium level of 12.6 mg/dL; CT scan of the head shows no abnormalities.
The most appropriate next step in management is:
A. Low-calcium diet with oral phosphate supplementation.
B. MRI of the neck.
C. Oral diphsophonate therapy.
D. Subcutaneous calcitonin therapy.
E. Surgical exploration of the neck.
Kindly substantiate your answers.
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| Idiopathic
Forum Guru
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That calcium level looks like an emergency to me. I would actually diurese this woman first. Without that, would bisphosphanate therapy help clear some calcium? I guess the question is whether or not she seems symptomatic.
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| tess
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go with d. 8)
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| asmi
Forum Hero
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For B
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| docdoc
Forum Senior
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The patient is a diagnosed case of hyperparathyroidism.
Medical management is tried if patient is aysmptomatic or calcium < 11.5. This patient is symptomatic (CNS symptoms are consistent with hyperparathyroidism) and Ca is above 12. Choices A, C and D are pretty much ruled out.
So I think only option is a surgical treatment. However there is no emergency situation in which surgical exploration of the neck is necessay. I think elective surgical removal can be done, by starting the work-up with an MRI.
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| guayoman
Forum Elite
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Medical management is tried ---according to Blue Prints--- when Ca is more than 12, not less than 11.5. It also states that your priority is lowering Ca. First IV NS; then, Calcitonin SC (works in hours) or Biphosphonates PO (work in 2 to 3 days). ONLY AFTER YOU HAVE NORMALIZED Ca you turn your attention to underlying diseases by invasive procedures. So B and E are ruled out FIRST. Than, you have to see which is the BEST answer of the remaining 3. Are you gonna alter her diet? ( not good enough is my guess); are you gonna give her Cacitonin or Biphosphonates? (I think that with her present neurologic condition you want to lower her Ca right away). So D sounds like the best option for me.
I took in consideration your inputs and a couple of paragraphs from Blue Prints. I don´t feel comfortable with this book though. I´m lacking a little in my preparation and this book is somewhat superficial. Can anyone reccomend literature for this test? I´m starting my prep and I´m quite lost.
Thanks
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| chemamr
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i think it´s bisphosphonates.
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