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Old 04-14-2012
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Question A 44 year old woman for regular check up

A 44 year old female patient coming to the office for a regular check up. Her vitals are BP 130/80, Pulse 80 bpm, RR 14/min, temprature 37.2C. She does not have any complaints. Her system examination is not remarkable. She's not currently on any medication. Her blood tests are as following: Na 134 mmol/l, K 3.8 mmol/l, Ca 11mg/dl, Urea 12mg/dl, Creatinine 0.6mg/dl, Hb 11mg/dl, WBC 8000 cells/mm, Neutrophils 70% Lymphocytes 25%, PTH 70 pq/ml (elevated), Urine Calcium 40mg/day (decreased). Which of the following choices would be an appropriate next step:

a- Start iv fluids 4L per day
b- Give iv Furosemide
c- Get blood Calcium levels from the patient's family
d- Give Bisphosphonates
e- Order CT scan of the chest, Blood PSA, Bone scan
f- Technicium Scan for the parathyoid for a parathyroid adenoma
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Old 04-16-2012
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is it C? Familial hypocalciuric hypercalcemia?
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Old 04-16-2012
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The correct answer is C

This is a case of Familial Hypocalcuric Hypercalcemia (FHH). As the name implies, Calcium levels are slightly elevated or at the upper high normal range, and the urine calcium is lower than normal. The disease is due to insensitivity of the calcium sensors in the parathyroid to calcium levels, so there would be little feed back inhibition of the parathyoid hormone production, and upper than normal calcium levels are needed to suppress PTH production. As a result, PTH is high normal or slightly elevated. Screening family members for hypercalcemia confirms the diagnosis.

The first step in the diagnosis of a case of hypercalcemia is to order PTH levels. If they are high, order urine calcium. Normal or high urine calcium is found in primary hyperparathyroidism, while normal urine calcium is found in FHH. If PTH is low, you have to rule out malignancies.

Very high calcium concentration require aggressive management. First line is replinish body fluids by 4-6 Liters of NS. If this is not enough, furosemide should be given. In extreme cases, dialysis, Prednisolone, calcitonin can be helpful. Bisphosphonates have delayed (2 to 3 days) but persistent action (weeks).
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