Student case two: the bad belly

[winterallsummer]

Good job. I gave calcitonin however deferred use of bisphosphonate to the endocrinologist - I don't know its role in parathyroid adenoma off the top of my head but maybe you can look this up later for your own interest. Calcitonin acts directly to oppose PTH and can be dosed 100-200 IV BID. It is typically used when the Ca is greater than 12 in these situations, and can be stopped when the Ca is lower.

 

For fluids she is euvolemic. However fluids will help her body clear the excess calcium. She had good kidneys and no heart failure (HF) or hypoalbunemia or other reason she couldn't tolerate excess fluids. I put her at 200 ml/hr of NS. Often this will turn your patients hyperchloremic and you must switch to 1/2 NS after a day or two. This by no means is a primer on fluids (maybe later) and in the wrong setting this much fluid can get sicker patients in a lot of trouble (unless of course they are hypovolemic and need it, but sometimes even then.)

 

Indeed her Ca did normalize by the end of her hospitalization. Sixteen is very high however so it still took a little while.

 

My go to bowel regimen is Senna S BID and miralax QD. Milk of mag also works well. Correction of her underlying issue also helps of course.

 

As stated above she did indeed have a parathyroid adenoma as seen on the ultrasound and confirmed with the high PTH and otherwise negative work up.

 

These PTH adenomas are functional but lack malignant potential. However in extremely rare cases you can get a parathyroid tumors which is malignant, but this is very rare.

 

The final steps were to first obtain nuclear imaging (sestamibi scan) which better localizes the tumor. For this scan any thyroid medication must be held. However calcitonin will not interfere. In this scan the adenoma binds preferentially to the nuclear medication and is well visualized on imaging, typically CT with SPECT. Finally the specialists (endocrinology and surgeon - ENT or in some larger practices sub specialists who specialize in endocrine tumors) were consulted. The patient was reassured and had an otherwise uneventful course thereafter. The parathyroid adenomectomy used to include bilateral neck exploration. However with advanced imaging, minimally invasive techniques are more typical at many centers.

 

Final points. And let me add this case is purely imaginary and any resemblance to anyone is one hundred percent coincidental.

 

1) hypercalcemia is most commonly due to hyperparathyroidism (functional or a tumor or secondary or tertiary) in the clinic or a paraneoplastic syndrome of malignancy in the hospital (any cancer is fair game). Always check for other simple causes such as dehydration, hypothyroidism, and medication side effects. The ESRD patient may have more complex causes such as calciphylaxis.

 

2) the general work up includes PTH, PTH-related-peptide, TSH and free T4, CBC and CMP. Anectodally I believe a CXR and KUB may be considered but further studies should be guided by the presentation.

 

3) a parathyroid adenoma is a somewhat common cause of hypercalcemia. The first line imaging modality is neck ultrasound. If a mass is found then more sophisticated nuclear imaging is warranted for surgical planning. A high PTH and otherwise negative work up plus imaging showing probable adenoma solves the case. At that point surgery and endocrinology consultation is warranted.

 

4) the treatment includes fluids unless contraindicated, calcitonin generally when the Ca is 12 or greater, and symptomatic medication such as a bowel regimen for constipation and Tylenol for abdominal pain.

 

Hope everyone enjoyed.

[DiggySRNA]

I enjoyed it....even though I was way off haha. 

[cinntsp]

urinalysis

GFR and creatine levels

hcg results, if negative, order A&P w/ contrast ct

 

 

 

....that's all I can think of

 

Any time you want to order a test it's important to think through what you are hoping to gain from a result and also question whether there is something less invasive available to you.  A CT A&P is very radiation(and cost)-intensive.  At the time of your reply, we knew it was a female with some ongoing mild lower abdominal pain, decreased appetite, and hypertension.  Checking a bhcg in a young female is a great thought and getting some basic labs as well.  The OP mentions a KUB is pending.  Is there something high on our differential at this point that would require a CT A&P right now vs. at least waiting for the x-ray results?  

 

CT A&P is the radiation equivalent of about 100 CXR straight to the babymaker.  The KUB is only about 8 CXR.  Keep in mind this is a young patient.  Radiation may not be as big of a concern in the 80yo little old lady.  This reply isn't to call you out, but to impress upon everyone the importance we have as providers to think about how our choices can affect patients down the road.  We get somewhat desensitized to this and say "yeah, just get the CT" to save some time and effort.