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.