Case StudyKatie Scanlon
Spring NUR 680
History of Present Illness
Information provided by the patient
Chief Complaint: “My calcium level is high”
HPI: B. T. is a 72 year old female who was referred to the endocrinology clinic d/t a repeatedly high serum calcium level. Pt denies current use of supplemental calcium or vitamin D. She states that she has taken a vitamin D supplement, but not within the last 3 years. B. T. denies history of calcium supplement use. She states she eats cheese a couple times a week and has occasional intake of yogurt. Denies drinking milk or eating dark leafy greens. States having generalized aches, pt has osteoarthritis. Denies recent fall or fracture. Ankle fracture 20 years ago d/t fall on ice, no history of non-traumatic fracture. She states her last bone density was about 10 years ago. Denies personal history of osteoporosis or family history of osteoporosis. Denies depression or feelings of increased fatigue.
Review of Systems
General: Denies fever, denies weight gain, weight loss, fatigue, malaise, change in appetite.
Respiratory: Denies SOB, difficulty breathing, cough, wheezing.
Cardiovascular: Denies chest pain, pressure, palpitations, irregular heart beat, or syncope.
GI: Denies diarrhea, constipation, coughing up blood, or blood stools. Positive for acid reflux
GU: Denies history renal calculi. Positive for UTI
Skin: Denies rash, lesions, changes in skin, changes in hair or nails.
Musculoskeletal: Denies non-traumatic fracture. Positive ankle fracture 20 years from fall
Past Medical History
Medical Illnesses: Spinal Stenosis, GERD, Rheumatic fever, HTN, UTI, osteoarthritis, low vitamin D
Hospitalizations/Surgeries: Hysterectomy, Appendectomy, Right knee replacement (2009), Right hip replacement (2011)
Immunizations: Influenza 10/14, pneumococcal 2008
Medications: Norco 7/325 PRN, Nexium 40mg PO daily, Gabapentin 300 PO BID, HCTZ 12.5mg PO daily, Oxybutin 5mg PO daily, Altace 10mg PO daily, Mobic 7.5 mg daily
Allergies: No known Seasonal, food, drug, or latex allergies
Social: Lives at home with husband who is on dialysis 3 x's/week; 3 adult children (2 daughters, 1 son). Denies use of alcohol or elicit drugs. Former smoker: quit 1981.
Family: Mother deceased age 65: Uterine CA; Father deceased age 85: MI, Colon CA; Sister: Diabetes Type 2; Daughter: Hypothyroid
Objective Findings
Vitals: 36.8-73-18-132/82 Weight 104.3kg Height 5' 4” BMI 39.3
General: Well appearing, well nourished female, appears stated age. Alert and oriented x's 3. Dress appropriate for season. Good hygiene.
Mouth/throat: Oral mucosa moist and intact. Uvula midline. No lesions.
Neck: Symmetrical, supple, thyroid not enlarged. No anterior or posterior cervical lymphadenopathy
Lungs: Clear to auscultation bilaterally. No adventitious breath sounds - no wheezing, crackles, or rhonchi. Regular respiratory rate and rhythm.
Heart: S1-S2 heart sounds. No murmur, rub, click, or gallop
Peripheral vascular: +2 brachial, radial, and pedal pulses. No edema
Skin: Color consistent with race. No lesions or discoloration.
GU: No CVA tenderness
Labs: December 2014: Parathyroid 83 (H); Calcium 10.4 (H);
We needs more info… Additional labs: Vitamin D, Magnesium, Phosphorus, TSH, SPEP
(Serum Protein Electrophoresis)
Urine: n-telopeptide (marker for bone turn over) May need a 24 hour urine depending on results of these tests
Bone Density ordered
Differential Diagnosis Primary Hyperparathyroidism
Familial Hyperparathyroidism
Secondary Hyperparathyroidism
Malignancy
Additional Lab Values
Phosphorus: 3.5 (Normal)
Vitamin D: 22 (Low Normal)
TSH: 2.3 (Normal)
Creatinine: 0.9 (Normal)
Magnesium: 1.7 (Normal)
Labs from December 2014: PTH 83 (H), Calcium 10.4 (H)
Patient’s Diagnosis Primary Hyperparathyroidism – 252.01
Treatment for this Patient2000 IU vitamin D daily
Recheck labs in 12 weeks
PCP notified and suggested to change HCTZ to a different medication
What are the Parathyroid glands?
4 parathyroid glands – 2 on each side of the thyroid
Role of these glands: secrete parathyroid hormone (PTH), which helps regulate blood calcium levels
Fuleihan, 2014; University of Michigan Department of Surgery, 2012
Primary Hyperparathyroidism Most common cause of elevated serum calcium levels in the general public
Occurs more often in women than men, with the average age being 65
Causes of Primary Hyperparathyroidism Exposure to radiation of the head and neck – usually 20-40 years before
developing hyperparathyroidism
Thiazide medications – reduce calcium excretion in the urine can lead to mild hypercalcemia
Lithium – increases PTH, ionized calcium and total calcium within weeks, remain within normal limits for most individuals
Adenoma (noncancerous growth) – most common causes
80% are single adenoma cases (1 overactive gland)
Other causes: Hyperplasia, Malignancy
Most cases occur randomly, but some are causes by inherited genes
Normal Feedback Mechanism
Low Serum Ca+ Level High Serum Ca+ Level
Parathyroid releases PTH Parathyroid decreases amount of PTH released
Ca+ released from the bones,
increased absorption of Ca+ in
the intestines, kidneys excrete
less Ca+
University of Michigan Department of Surgery, 2012
Pathophysiology of Primary Hyperparathyroidism
Unregulated production and release of PTH by the parathyroid hormone, leading to increased serum calcium level
Increase in calcium released from the bones
Increased reabsorption of calcium from the kidneys
Increased absorption of calcium in the GI tract
Wood & Lock, 2013
Symptoms
“Moans, bones, groans, and stones”
Osteoporosis
Joint pain
Kidney stones
Abdominal pain
Depression
Fatigue
Forgetfulness
Nausea/vomiting
Lack of appetite
May cause cardiac disease
HTN
CAD
Atherosclerosis
Arrhythmia
Left ventricular hypertrophy
Diagnosis
Lab work: Calcium, PTH, Vitamin D, n-telopeptide, GFR, Creatinine
Vitamin D deficiency will never cause serum calcium to be elevated
Bone density
24 hour urine
Imaging the kidneys
If surgery is recommended:
Ultrasound
Sestamibi parathyroid scan
Fuleihan & Silverberg, 2013; Michigan University Department of Surgery, 2012; Pagana & Pagana, 2006; Wood & Lock, 2013
Treatment
Non-surgical
Avoid lithium & thiazides
Exercise/Remain active
Remain hydrated (reduced risk of development of kidney stone)
Maintain moderate amount of Calcium (1000mg daily)
Low calcium intake will cause increase in PTH secretion
Take moderate amount of Vitamin D
Bisphosphonates to help prevent/reduce bone loss
Can only take total 5 years
Surgery
Removal of overactive parathyroid gland
Only known cure for primary hyperparathyroidism
Columbia Univerity Department of Surgery, nd,; Fuleihan, 2014; Mayo Clinic, 2014
ReferencesColumbia University Department of Surgery. (nd.). Primary hyperparathyroidism. Retrieved from
http://www.columbiasurgery.org/parathyroid/primary_hyperparathyroidism.html
Fuleihan, G. E. H. (2014). Patient information: Primary hyperparathyroidism (beyond the basics). Retrieved from http://www.uptodate.com/contents/primary-hyperparathyroidism-beyond-the-basics
Fuleihan, G. E. H. & Arnold, A. (2014). Pathogenesis and etiology of primary hyperparathyroidism. Retrieved from http://www.uptodate.com/contents/pathogenesis-and-etiology-of-primary-hyperparathyroidism?source=search_result&search=hyperparathyroidism&selectedTitle=4%7E150
Fuleihan, G. E. H & Silverberg, S J. (2013). Diagnosis and differential diagnosis of primary hyperparathyroidism. Retrieved from http://www.uptodate.com/contents/diagnosis-and-differential-diagnosis-of-primary-hyperparathyroidism?source=search_result&search=hyperparathyroidism&selectedTitle=1%7E150
Mayo Clinic. (2014). Hyperparathyroidism. Retrieved from http://www.mayoclinic.org/diseases-conditions/hyperparathyroidism/basics/causes/con-20022086
Pagana, K. D. & Pagana, T. J. (2006). Mosby’s manual of diagnostic and laboratory tests (3rd ed.). St. Louis, MO: MOSBY Elseiver.
University of Michigan Department of Surgery. (2012). Primary hyperparathyroidism. Retrieved from http://
surgery.med.umich.edu/general/endocrine/patient/conditions/parathyroid/primary_hyperparathyroidism.shtml
Wood, K. D., & Lock, J. P. (2013). The 5-minute clinical consult (21st ed.). F. J. Domino (Ed.). Philadelphia, PA: Lippincott Williams & Wilkins.