Download Question 1 - Endoselfassessment.org

Calcium-Bone MOC 2011
Question 1
A 38-year-old woman is referred to you for evaluation of hypercalcemia. She presented to her
primary care physician’s office 1 day earlier, and her calcium level was elevated. In addition, she
has a 2-week history of painful, red, circular lesions on both legs that are palpable (see
photograph). She has had some malaise, but no fever or chills. She has never had this type of rash
before and she has not had contact with anything out of the ordinary.
Her medical history is remarkable for type 2 diabetes mellitus treated with metformin, 1000 mg
twice daily. She has taken metformin for the past 4 years, although the dosage was increased 6
months ago from 1000 mg daily to the current regimen. She has no known medical allergies and
no relevant travel history.
On physical examination, blood pressure is 122/74 mm Hg, pulse rate is 98 beats/min, weight is
189 pounds, and height is 66 inches (BMI = 30.5 kg/m2). You confirm the finding of the rash.
The rest of her examination findings are normal.
Laboratory test results:
Creatinine = 0.9 mg/dL
Calcium = 12.4 mg/dL
Albumin = 4.0 g/dL
Phosphorus = 4.7 mg/dL
Chest x-ray from the day before shows clear lung fields without masses or infiltrate, but bilateral
hilar adenopathy is present.
Measuring which one of the following would most likely determine the cause of the
hypercalcemia?
A. PTH
B. PTHrP
C. 24-Hour urinary calcium
D. 25-Hydroxyvitamin D
E. 1,25-Dihydroxyvitamin D
Answer: E
Educational objective:
Evaluate hypercalcemia and consider the physiology and pathophysiology to determine the best
next diagnostic test.
Question 2
A 49-year-old premenopausal woman is referred to you for evaluation of decreasing bone mineral
density.
Her medical history is remarkable in that 1 year earlier, she presented with new-onset asthma.
DXA was performed at that time, which documented a lumbar spine T score of –1.7 and a
femoral neck T score of –1.5. After inhaled bronchodilator medications failed, she was prescribed
prednisone and has been unable to discontinue that medication. Her prednisone dosage has ranged
from the current level of 10 mg daily up to a maximum of 80 mg daily.
In follow-up of her overall medical condition, another DXA was performed the week before her
visit with you, which showed significant decreases in bone mineral density of 6.2% at the spine
and 4.2% at the hip.
She has regular menses. She takes calcium, 1000 mg daily, and over-the-counter vitamin D, 800
IU daily.
On physical examination, blood pressure is 132/82 mm Hg, pulse rate is 88 beats/min, weight is
145 pounds, and height is 65 inches (BMI = 24.1 kg/m2). Her examination findings are
unremarkable except for a mildly cushingoid habitus and scattered rhonchi on pulmonary
examination.
Which one of the following assessments is most likely to be normal?
A. Urinary cross-linked N-telopeptide of type 1 collagen
B. T score at the ultradistal radius
C. Osteocalcin concentration
D. 24-Hour urinary calcium
E. Calcium absorption
Answer: C
Educational objective:
Discuss the effects of glucocorticoids on bone mass and evaluate patients with decreasing bone
mineral density.
Question 3
A 58-year-old man is referred to you for evaluation of bilateral upper leg pain. The pain is dull
and aching and has been present in both legs for at least 2 years, but it seems worse in recent
months. He has no history of trauma and had no change in his activity level before the onset of
the problem. He is active, but does not regularly exercise.
He had 2 metatarsal stress fractures as a young adult. He also has a notable history of arthritis,
with an episode of calcium pyrophosphate crystal arthropathy in the right knee 3 years ago. He
has a history of poor dentition dating back to childhood, which has led to him wearing full upper
and lower dentures. His father experienced similar problems with his dentition, as well as
multiple fractures.
On physical examination, blood pressure is 130/80 mm Hg, pulse rate is 70 beats/min, weight is
190 pounds, and height is 70 inches (BMI = 27.3 kg/m2). His examination is remarkable for
bilateral thigh pain with palpation, although there is no warmth, redness, or femoral bowing.
Laboratory test results:
Calcium = 9.2 mg/dL
Phosphorus = 4.0 mg/dL
Albumin = 4.0 g/dL
On the basis of his history and physical examination findings, you order a thorough biochemical
evaluation. Plain x-rays of both femurs reveal osteopenia.
You anticipate an abnormality in which one of the following serum tests?
A. Alkaline phosphatase
B. PTH
C. 25-Hydroxyvitamin D
D. 1,25-Dihydroxyvitamin D
E. PTHrP
Answer: A
Educational objective:
Diagnose hypophosphatasia in an adult.
Question 4
You are asked to develop a therapeutic plan for a 62-year-old woman with primary
hyperparathyroidism. She has a history of hypercalcemia, nephrolithiasis, and low bone mineral
density. At initial presentation, her calcium concentration was 12.6 mg/dL with a PTH
concentration of 100 pg/mL. She has had kidney stones on 2 occasions. On the basis of these
findings, she had parathyroid ultrasonography, which localized a solitary adenoma. She
underwent successful resection of that adenoma 1 month before your visit. Her calcium has
normalized postoperatively, and she is feeling well.
On physical examination, blood pressure is 132/80 mm Hg, and heart rate is 80 beats/min.
Examination of the head, eyes, ears, nose, and throat shows a healing scar with no other
abnormalities. She has a negative Chvostek sign. The rest of her examination findings are normal.
Biochemical evaluation documents normal electrolytes with a calcium concentration of 9.1
mg/dL. DXA reveals the following T scores: lumbar spine, –2.4; femoral neck, –2.6; and
ultradistal radius, –3.0.
Which one of the following therapeutic options is best for her in the coming year?
A. Alendronate, 70 mg weekly
B. Conjugated estrogens, 625 mcg daily, and medroxyprogesterone, 5 mg daily
C. Teriparatide, 20 mcg subcutaneously daily
D. Calcitonin salmon nasal spray, 200 IU daily
E. No therapy is indicated
Answer: E
Educational objective:
Determine whether therapy to improve bone mineral density is needed in a patient after
parathyroidectomy.
Question 5
A 29-year-old man presents to his primary care physician with fatigue. He has had no medical
examinations since childhood. In the last couple of years, he has felt that his energy level at work
has been decreasing, although he does not report any specific weakness or other neuromuscular
symptoms. His primary care physician documents unremarkable findings on physical
examination and orders laboratory work. She is called emergently when the patient’s calcium
concentration is measured (and double checked) at 11.4 mg/dL. The physician then sends the
patient to you for an urgent consultation.
He has no surgical history. His family history is generally unknown, but he does not recall anyone
in the family having kidney stones or fractures.
On physical examination, blood pressure is 112/70 mm Hg, height is 69 inches, and weight is 155
pounds (BMI = 22.9 kg/m2). Examination findings, including those from examination of the head,
eyes, ears, nose, and throat, are normal, with no masses or adenopathy.
Laboratory test results:
Calcium = 12.0 mg/dL
Albumin = 3.9 g/dL
PTH = 41 pg/mL
25-Hydroxyvitamin D = 40 ng/mL
1,25-Dihydroxyvitamin D = 41 pg/mL
Urinary calcium = 14 mg/24 h
Urinary creatinine = 1.0 g/24 h
Ratio of calcium clearance to creatinine clearance = 0.008
Which one of the following is the best next therapeutic step?
A. Observation
B. Oral cinacalcet
C. Neck exploration with excision of largest parathyroid gland
D. Intravenous pamidronate
E. Oral prednisone
Answer: A
Educational objective:
Determine the best management step after diagnosing familial hypocalciuric hypercalcemia.
Question 6
A 40-year-old man is referred to you for evaluation of hypocalcemia. For the past month, he has
been having myalgias and some sporadic twitching of various muscles.
His medical history is remarkable for idiopathic cardiomyopathy for which he underwent heart
transplant 2 years ago. He currently takes cyclosporine, azathioprine, and furosemide.
The transplant team ordered a chemistry panel that was notable for a slightly elevated creatinine
concentration of 1.3 mg/dL, which was unchanged from previous measurements, along with a
calcium concentration of 7.8 mg/dL. He is sent to you for further evaluation.
Findings from his physical examination are remarkable for a positive Chvostek sign and trace
bilateral pedal edema.
Laboratory test results:
Calcium = 7.9 mg/dL
Albumin = 4.0 g/dL
Creatinine = 1.2 mg/dL
Phosphorus = 4.4 mg/dL
PTH = 10 pg/mL
Which one of the following assessments should you order next?
A. PTHrP measurement
B. Technetium Tc 99m pyrophosphate bone scan
C. Serum protein electrophoresis
D. Magnesium measurement
E. Urinary cross-linked N-telopeptide of type 1 collagen
Answer: D
Educational objective:
Suspect hypomagnesemia as the cause of hypocalcemia.
Question 7
A 64-year-old man presents with hypercalcemia. Over the past 2 months, he has developed
“bumps” on his neck and groin. He has had bilateral lower extremity aching and feels that his
muscle strength is diminished as well. He has had no fevers or chills. He has lost 3 to 5 pounds
over this period.
His medical history is remarkable only for hypertension. He is treated with metoprolol, 50 mg
daily. He has no allergies and no history of relevant travel.
On physical examination, blood pressure is 110/64 mm Hg, and heart rate is 66 beats/min. Eye
examination shows dilated, segmented, and tortuous retinal veins in a “sausage link” appearance.
Chest is clear to auscultation and percussion. Cardiac examination findings are normal.
Hepatosplenomegaly is detected on abdominal examination. He has palpable inguinal, cervical,
and axillary adenopathy.
Laboratory test results:
White blood cell count, normal
Hematocrit = 28.8%
Rouleaux formation noted on complete blood cell count
Erythrocyte sedimentation rate = 88 mm/h
Total protein = 9.5 g/dL
Albumin = 4.0 g/dL
Calcium = 11.0 mg/dL
Creatinine = 1.0 mg/dL
Phosphorus = 4.0 mg/dL
As you proceed with evaluation of his hypercalcemia, which one of the following patterns would
you expect?
Ionized
calcium
PTH
1,25-Dihydroxyvitamin D
A
Normal
Normal
Normal
B
Increased
Decreased
Increased
C
Increased
Increased
Increased
D
Normal
Increased
Decreased
E
Decreased
Increased
Decreased
Answer: A
Educational objective:
Predict the pattern of laboratory analytes expected with paraproteinemias.
Question 8
A 26-year-old man, his fiancée, and his parents come to you for advice regarding the heritability
of his medical condition.
He carries a diagnosis of pseudohypoparathyroidism (type 1a), and he and his fiancée want to
know the risk that their children will have the same condition.
His medical history includes reaching an adult height that is 3 inches shorter than his midparental height, some difficulty with grades in school (but he was able to complete high school),
and difficulty maintaining his weight in the normal range.
He has been treated with calcitriol and calcium supplementation throughout his life. Puberty
occurred at age 14 years, and he has no history of other endocrine diseases, including thyroid
dysfunction.
Physical examination reveals an obese man; he is 65 inches tall and weighs 192 pounds (BMI =
31.9 kg/m2). Blood pressure is 122/78 mm Hg, and heart rate is 86 beats/min. Examination
findings of the head, eyes, ears, nose, and throat are unremarkable, with a negative Chvostek sign.
Extremity examination reveals brachydactyly and 2 subcutaneous ossifications in each lower
extremity.
Regarding the patient’s question about risk to future offspring, which one of the following is
true?
A. All offspring will have normal calcium levels
B. Each child has a 50% chance of having the same manifestations
C. All offspring will have the same manifestations
D. Each child has a 50% chance of having only hypocalcemia
E. All offspring will have Albright hereditary osteodystrophy
Answer: A
Educational objective:
Apply principles of genomic imprinting to provide patients information about recurrence risk in
the setting of pseudohypoparathyroidism type 1a.
Question 9
While walking her dog and stepping off a curb, a healthy 65-year-old woman experiences sharp
lower back pain. She seeks medical attention and is found to have an acute lumbar compression
fracture of the third vertebra. Evaluation for secondary causes does not document any abnormal
results (serum and urine protein electrophoresis, chemistry panel, TSH, 25-hydroxyvitamin D,
complete blood cell count, chest x-ray).
Her family history is remarkable for her mother who sustained a hip fracture at age 88 years. The
patient smokes 1 pack of cigarettes per day and has done so for 40 years. She takes no
medications and has no allergies. Menarche was at age 16 years. She had a hysterectomy and
bilateral oophorectomy at age 46 years for dysfunctional uterine bleeding and endometriosis. She
has never taken hormone replacement therapy. She has no history of steroid use.
You order DXA, and her lumbar spine and femoral neck T scores are –2.6.
Which one of the following factors in her history is the best predictor of future osteoporotic
fracture?
A. T scores of –2.6
B. Parental history of hip fracture
C. Lumbar spine compression fracture
D. Active smoking history
E. Age at menarche
Answer: C
Educational objective:
Determine the risk factor for fracture that best predicts future fracture risk.
Question 10
A 60-year-old woman presents to your office for evaluation of fatigue and fractures. Over the past
2 years, she has felt progressively more tired with exertion and has had a slow but steady
diminution in her activity level. In addition, she has had 5 fractures over that period: both wrists
with falls, right fibula with an ankle sprain, and 2 ribs with coughing. The fractures all healed in
an appropriate time frame, and she has no current symptoms at any of those sites.
She initially presented to her primary care physician who measured her calcium and 25hydroxyvitamin D levels on 2 occasions; these measurements were within the reference range. He
prescribed calcium supplementation, 1200 mg daily, and referred her to you for further
evaluation.
Physical examination findings are generally unremarkable except for diffuse and mild weakness
throughout her upper and lower extremities.
Laboratory test results:
Calcium = 9.0 mg/dL
Phosphorus = 1.0 mg/dL
Albumin = 3.7 g/dL
Alkaline phosphatase = 130 U/L
PTH = 33 pg/mL
Which one of the following analytes is likely to be increased when you perform further testing?
A. 24-Hour urinary calcium
B. Fibroblast growth factor 23
C. IGF-1
D. IGF-2
E. 1,25-Dihydroxyvitamin D
Answer: B
Educational objective:
Diagnose oncogenic osteomalacia and determine the pathologic mediator of that condition.
Question 11
You are asked to see a 58-year-old white woman for decreasing bone density while taking
alendronate. She underwent DXA for the first time 14 months earlier for screening purposes,
which documented T scores of –2.6 at the spine and –2.2 at the hip. She has no history of
fracture. Menarche was at age 12 years and menopause was at age 51 years. She has never taken
estrogen replacement therapy. She is generally very active, walking 30 minutes at least 4 to 5
times per week.
Laboratory test results at initial evaluation:
25-Hydroxyvitamin D = 39 ng/mL
Calcium = 8.9 mg/dL
Urinary calcium = 175 mg/24 h
TSH = 1.1 mIU/L
Serum and urine protein electrophoresis, normal
She was prescribed alendronate, 70 mg weekly. After 1 year, DXA was performed again, which
now shows significant decreases of 4.8% at the spine and 2.7% at the hip. She is referred to you
for an opinion on the next step in her care.
She does not smoke cigarettes, has never taken glucocorticoids, and has no history of thyroid
disease. Her mother has osteoporosis and is currently being treated with alendronate as well. The
patient is taking the medication regularly and correctly and has experienced no adverse effects.
Physical examination findings are entirely normal. You order a repeated laboratory workup, and
again all parameters are normal, including a urinary calcium excretion of 202 mg/24 h. In
addition, you order measurement of serum cross-linked N-telopeptide of type 1 collagen to
evaluate the rate of bone turnover; the value is elevated at 64 nM BCE.
Which one of the following is the best next step?
A. Continue the current alendronate regimen
B. Change to an intravenous bisphosphonate
C. Increase vitamin D intake
D. Increase calcium intake
E. Begin an aggressive exercise and weight-training regimen
Answer: B
Educational objective:
Select an alternative treatment strategy for low bone mineral density when antiresorptive therapy
fails.
Question 12
A 68-year-old woman is evaluated for hypercalcemia. During an evaluation following passage of
a calcium-based kidney stone, an elevated calcium concentration of 12.3 mg/dL was documented.
Six years earlier, her calcium level was measured as part of a chemistry panel, and the value was
within the reference range. Physical examination findings are normal.
Laboratory test results:
25-Hydroxyvitamin D = 27 ng/mL
1,25-Dihydroxyvitamin D = 65 pg/mL
Urinary calcium = 392 mg/24 h
You order DXA as part of the evaluation.
Which one of the following patterns of T scores would you predict to find?
A
B
C
D
E
Lumbar
Spine
0.1
–1.2
–1.8
–2.9
–1.5
Femoral
Neck
–2.9
–1.1
0.4
0.2
–1.9
Distal
Radius
–1.0
–1.2
–1.7
0.6
–2.6
Answer: E
Educational objective:
Predict patterns of bone mineral density in medical conditions such as primary
hyperparathyroidism.
Question 13
A 55-year-old man is admitted to the hospital for hypercalcemia, and you are asked to see him in
consultation.
He presented to his primary care physician’s office 6 months ago for a general health
examination. A 25-hydroxyvitamin D level measured on routine screening was 12 ng/mL. He was
feeling well at the time and had no history of weight loss, loose stools, or change in his bowel
habits.
Workup was negative for other signs of fat malabsorption, as well as celiac disease, and he was
prescribed calcium supplementation, 2400 mg daily, along with ergocalciferol, 50,000 IU weekly.
Approximately 2 months later, a friend advised him to start some additional nutritional
supplements, which included more vitamin D. When you examine these pills, it appears that he is
taking 6000 IU of vitamin D daily, in addition to the ergocalciferol.
During a follow-up appointment with his primary care physician, the duplication in medication
was uncovered. Laboratory studies revealed the following values: calcium, 14.9 mg/dL; 25hydroxyvitamin D, 141 ng/mL; and PTH, undetectable.
Which one of the following would be the most effective initial treatment for the hypercalcemia?
A. Intravenous pamidronate
B. Nasal calcitonin
C. Subcutaneous calcitonin
D. Intravenous fluids and furosemide
E. Intravenous mithramycin
Answer: D
Educational objective:
Select the best treatment option for hypercalcemia caused by excess amounts of exogenous
vitamin D and calcium.
Question 14
A 60-year-old woman comes to your office regarding low bone mineral density.
She has an unremarkable medical history. She had screening heel DXA at age 53 years (at
menopause), which, by report, was normal. She has never taken estrogen, but does take calcium
supplements, 600 mg daily. DXA done 2 months ago revealed a T score of –2.7 at the spine and –
2.6 at the hip. She is upset by the findings and would like your opinion on how to proceed.
She has no family history of osteoporosis or fracture. She does not smoke cigarettes. She is
active, has no personal history of fracture, and has never taken steroids.
On physical examination, blood pressure is 128/84 mm Hg, and heart rate is 88 beats/min. You
detect a small, diffuse goiter that is not tender. Lungs are clear, and cardiac examination findings
are normal. There is no peripheral edema, and reflexes are normal. There are no signs of
hypercortisolism.
Laboratory test results:
Calcium = 9.0 mg/dL
Phosphorus = 2.3 mg/dL
PTH = 60 pg/mL
Albumin = 3.8 g/dL
25-Hydroxyvitamin D = 9 ng/mL
TSH = 1.2 mIU/L
Free T4 = 1.0 ng/dL
Serum and urine protein electrophoresis, normal
Which one of the following is the best initial treatment option?
A. Alendronate, 70 mg weekly
B. Alendronate, 35 mg weekly
C. Ergocalciferol, 50,000 IU weekly
D. Ergocalciferol, 50,000 IU weekly, and alendronate, 70 mg weekly
E. Ergocalciferol, 50,000 IU weekly, and alendronate, 35 mg weekly
Answer: C
Educational objective:
Treat hypovitaminosis D before the use of antiresorptive agents.
Question 15
A 55-year-old woman is referred to you for treatment following a spontaneous lumbar
compression fracture that occurred after she picked up a garbage can 3 weeks ago. Plain films
confirmed the compression fracture and also documented diffuse osteopenia.
Her medical history is remarkable for chronic renal insufficiency secondary to previously poorly
controlled hypertension. Her estimated glomerular filtration rate is 22 mL/min. Her current
medications include metoprolol, minoxidil, furosemide, and amlodipine. She does not smoke
cigarettes, drink alcohol, or have a history of immobility.
On physical examination, blood pressure is 134/84 mm Hg, and heart rate in 78 beats/min. On
palpation, there is some tenderness over L3. Examination findings are otherwise unremarkable
except for trace bilateral pedal edema.
Laboratory test results:
Calcium = 8.2 mg/dL
Albumin = 3.5 g/dL
Phosphorus = 4.7 mg/dL
PTH = 60 pg/mL
25-Hydroxyvitamin D = 31 ng/mL
TSH = 1.02 mIU/L
Serum and urine protein electrophoresis, normal
DXA shows T scores of –2.9 at the lumbar spine and –2.8 at the femoral neck.
Which one of the following therapies is the best to treat the patient’s low bone density?
A. Denosumab
B. Alendronate
C. Ibandronate (intravenous)
D. Calcitonin salmon
E. Teriparatide
Answer: A
Educational objective:
Identify the contraindications for certain pharmacologic treatments of osteoporosis.
Question 16
A 52-year-old man is seen for evaluation of possible primary hyperparathyroidism.
Hypercalcemia was noted on screening laboratory studies part of a routine annual physical
examination. He has no history of nephrolithiasis. He has no family history of similar calcium
disturbances. He has always had normal blood pressure and has no history of peptic ulcer disease.
On physical examination, blood pressure is 134/84 mm Hg, and heart rate is 80 beats/min.
Examination of the head, eyes, ears, nose, and throat reveals no masses or adenopathy. Chest is
clear, and cardiac examination findings are unremarkable. Bowel sounds are normal, and he has
no hepatosplenomegaly or organomegaly. Neurologic examination findings are also normal.
Laboratory test results:
Calcium = 10.9 mg/dL
Phosphorus = 2.0 mg/dL
25-Hydroxyvitamin D = 26 ng/mL
Urinary calcium = 310 mg/24 h
PTH = 58 pg/mL
According to current published consensus statements, which one of the following is an indication
for surgical intervention in this patient?
A. Age of 52 years
B. Male sex
C. Serum calcium concentration of 10.9 mg/dL
D. PTH concentration of 58 pg/mL
E. Surgery is not indicated for this patient
Answer: E
Educational objective:
Diagnose primary hyperparathyroidism and identify indications for surgical intervention.
Question 17
A 48-year-old woman is sent to you for evaluation of low bone mineral density following her first
DXA scan. She is perimenopausal, and the scan was done for screening purposes. She has no
history of fracture, but her mother has osteoporosis and has been treated with risedronate for the
past 4 years.
Her medical history is remarkable for hyperlipidemia, hypertension, hypothyroidism, and
idiopathic seizures. All of these conditions have been well managed over the years, and she has
not had a seizure in at least 8 years. She takes calcium, 600 mg daily, and vitamin D, 800 IU
daily. Her medications include levothyroxine, simvastatin, phenytoin, hydrochlorothiazide, and
metoprolol.
Physical examination findings are unremarkable. The recent DXA scan reveals a lumbar spine T
score of –2.6 and a femoral neck T score of –2.5.
Laboratory test results:
Calcium = 8.8 mg/dL
Phosphorus = 2.7 mg/dL
25-Hydroxyvitamin D = 21 ng/mL
PTH = 61 pg/mL
TSH = 1.2 mIU/L
Which one of the following medications is most likely to have contributed to the low bone mineral
density?
A. Levothyroxine
B. Simvastatin
C. Phenytoin
D. Hydrochlorothiazide
E. Metoprolol
Answer: C
Educational objective:
Identify pharmacologic agents that cause loss of bone mineral density.
Question 18
A 36-year-old woman is seen for counseling. She has hearing loss that was detected in childhood
and has worsened over time. As a child, she sustained a Colles fracture and a fibular fracture. As
an adult, she has had 2 metatarsal fractures (at age 32 and 33 years) and a rib fracture (1 year
ago). Her mother has the same condition.
On physical examination, blood pressure is 114/70 mm Hg, and heart rate is 78 beats/min.
Examination of the head, eyes, ears, nose, and throat reveals blue sclerae and diminished
sensorineural hearing. The rest of her examination findings are normal.
DXA is performed, which reveals a T score of –2.0 at both the hip and spine. Chemistry values,
vitamin D concentration, and thyroid test result values are all normal.
If she were to have children with her husband (who is healthy), which one of the following
reflects the probability that their offspring will have the same condition as the patient?
A. Each child has a 50% chance of being affected
B. Each female child has a 50% chance of being affected, but none of the male children will be
affected
C. Each male child has a 50% chance of being affected, but none of the female children will be
affected
D. The probability depends on whether her husband is a carrier of a mutation in the diseasecausing gene
E. Each child has a 25% chance of being affected
Answer: A
Educational objective:
Diagnose osteogenesis imperfecta and apply principles of autosomal dominant inheritance to
provide patients information about recurrence risk.
Question 19
You are asked for your opinion regarding treatment of a 70-year-old man. Over the past 2 years,
although more so in the past 3 months, he has noticed pain and swelling over the upper left leg. It
is an aching pain that is more noticeable when he ambulates. He thinks that the warmth has been
there the entire time, but that the bowing/prominence of the area has slowly increased.
His medical history is remarkable for hypertension treated with lisinopril, 20 mg daily, and type 2
diabetes mellitus treated with glipizide, 5 mg daily. He has no fracture history and no family
history of any bone disease. He does not smoke cigarettes.
Physical examination reveals erythema, warmth, and lateral bowing over the right proximal
femur. There is some tenderness to palpation. Otherwise, his examination findings are normal.
Laboratory test results:
Calcium = 9.9 mg/dL
Creatinine = 1.1 mg/dL
Alkaline phosphatase = 480 U/L
Plain films of the area show cortical thickening with a mottled area of lucency and sclerosis. No
fracture is seen. The radiographs of the pelvis, hip, and femur are normal.
Which one of the following therapies is the most appropriate for this patient?
A. Alendronate, 70 mg weekly for 6 months
B. Alendronate, 40 mg daily for 6 months
C. Nasal calcitonin, 200 IU daily for 6 months
D. Risedronate, 30 mg daily for 1 year
E. Risedronate, 35 mg weekly for 1 year
Answer: B
Educational objective:
Diagnose Paget disease and prescribe the appropriate pharmacologic agent and dosage.
Question 20
A 66-year-old man comes to you with questions about therapy for his primary
hyperparathyroidism. This was recently diagnosed on evaluation after he passed a calcium-based
kidney stone.
Laboratory test results at the time of stone passage:
Calcium = 12.2 mg/dL
PTH = 88 pg/mL
25-Hydroxyvitamin D = 22 ng/mL
1,25-Dihydroxyvitamin D = 78 pg/mL
Urinary calcium = 390 mg/24 h
He takes amlodipine, 5 mg daily, for hypertension. He does not smoke cigarettes or drink alcohol.
His family history is unremarkable.
On physical examination, blood pressure is 148/90 mm Hg, and heart rate is 80 beats/min. The
rest of the examination findings are normal.
X-rays of the kidneys, ureter, and bladder are obtained, which show multiple small opacifications
in both kidneys. DXA is performed, and his T score at the hip is –2.9.
He is adamant that he does not want surgery, despite your advice. He would perhaps consider it in
the future. You agree to an off-label trial of cinacalcet, 30 mg daily, with dosage escalation to 60
mg daily after 2 weeks. You will then see him back in the office 2 weeks later.
You anticipate the greatest magnitude of change in which one of the following parameters?
A. Serum calcium concentration
B. PTH concentration
C. 25-Hydroxyvitamin D concentration
D. Fracture risk
E. Presence of kidney stones
Answer: A
Educational objective:
Predict the effects of calcium mimetic agents.
Question 21
Papillary thyroid cancer was recently diagnosed in a 33-year-old woman. She undergoes total
thyroidectomy, and the surgeon can only identify 3 parathyroid glands. He removes all 3,
performing an autotransplant of 1 into the left forearm. On the first postoperative day, the patient
does well and is able to eat and ambulate without difficulty. However, on the second
postoperative day, as she is preparing to be discharged, she notes cramping in her hands and
tingling around her mouth.
She was taking no medications before surgery. Liothyronine, 10 mcg twice daily, and calcium,
1000 mg twice daily, were prescribed after surgery.
Physical examination findings are remarkable for positive Chvostek and Trousseau signs.
Laboratory test results obtained that morning:
Calcium = 6.6 mg/dL
Albumin = 4.0 g/dL
Phosphorus = 4.0 mg/dL
Magnesium = 2.2 mg/dL
PTH, undetectable
25-Hydroxyvitamin D = 12 ng/mL
In addition to aggressive calcium supplementation, both oral and intravenous, which of the
following should be added to her regimen?
A. Ergocalciferol
B. Calcitriol
C. Magnesium
D. Lithium
E. Cinacalcet
Answer: B
Educational objective:
Develop a treatment plan for hypoparathyroidism with hypocalcemia.
Question 22
A 77-year-old man presents with hypercalcemia. He is a long-standing smoker and has a 45 packyear history. His symptoms include a long-standing, nonproductive cough that has worsened in
the past 3 months along with a 4-pound weight loss in the past 2 months. He reports no pain,
fractures, or kidney stones.
Physical examination findings are remarkable for diminished air exchange in the right upper lung
field. Extremity examination findings are notable for clubbing. Chest x-ray shows a 3-cm mass in
the right upper lobe, but no evidence of any bony changes.
Laboratory test results:
Calcium = 11.0 mg/dL
Phosphorus = 1.9 mg/dL
1,25-Dihydroxyvitamin D = 18 pg/mL
Which one of the following mediators/mechanisms is most likely responsible for the
hypercalcemia?
A. 25-Hydroxyvitamin D
B. PTH
C. PTHrP
D. Direct bone metastases
E. Fibroblast growth factor 23
Answer: C
Educational objective:
Recognize paraneoplastic syndromes with hypercalcemia.
Question 23
A 78-year-old woman is referred to you for evaluation of osteoporosis. She has had sequential
DXA scans over the years, and, in light of decreasing bone density, is now willing to undergo
treatment. Her most recent DXA shows a T score of –3.1 at both the hip and spine, representing a
6.5% decrease at the spine from 2 years ago.
Her medical history is remarkable for breast cancer treated with radiation and chemotherapy. She
also has renal insufficiency and hypertension. Her current medications include furosemide, 20 mg
daily, and amlodipine, 5 mg daily. She takes calcium supplements, 500 mg daily, and vitamin D,
600 IU daily.
On physical examination, blood pressure is 132/74 mm Hg, pulse rate is 88 beats/min, weight is
114 pounds, and height is 61 inches (BMI = 21.5 kg/m2). The rest of her examination findings are
normal.
Laboratory test results:
Creatinine = 1.4 mg/dL
Calcium = 8.8 mg/dL
25-Hydroxyvitamin D = 33 ng/mL
Urinary calcium = 225 mg/24 h
Urinary creatinine = 0.9 g/24 h
Which one of the following in this patient is a contraindication to starting teriparatide?
A. Age
B. History of chemotherapy
C. History of radiation therapy
D. Serum calcium concentration
E. Urinary calcium excretion
Answer: C
Educational objective:
Identify contraindications to the use of recombinant PTH in the treatment of osteoporosis.
Question 24
A 20-year-old woman is referred to you for evaluation of hypercalcemia. The elevated calcium
concentration (12.9 mg/dL) was detected on routine laboratory testing done at a local health fair.
Her primary care physician was contacted immediately. The test was repeated, and the elevated
value was verified.
She has a family history of hypercalcemia, with at least 3 affected first- and second-degree
relatives. None of her affected family members have a history of fracture or kidney stones.
On physical examination, blood pressure is 122/72 mm Hg, height is 63 inches, and weight is 135
pounds (BMI = 25.7 kg/m2). Examination findings, including those from examination of the head,
eyes, ears, nose, and throat, are normal, with no masses or adenopathy.
Laboratory test results
Calcium = 12.0 mg/dL
Albumin = 3.8 g/dL
PTH = 52 pg/mL
25-Hydroxyvitamin D = 50 ng/mL
1,25-Dihydroxyvitamin D = 42 pg/mL
Urinary calcium = 25 mg/24 h
Based on her likely diagnosis, which one of the following genetic mutations would you expect to
find?
A. Activating mutation of the calcium-sensing receptor
B. Inactivating mutation of the calcium-sensing receptor
C. Activating mutation of the vitamin D receptor
D. Inactivating mutation of the PTH receptor
E. Activating mutation of the PTH receptor
Answer: B
Educational objective:
Describe the physiology of calcium regulation and the mutations that cause calcium disorders,
including familial hypocalciuric hypercalcemia.
Question 25
A 55-year-old woman is seen for consideration of therapy for low bone mineral density. She does
not have a fracture history. Her first screening DXA earlier this month showed a T score of –2.8
at both the hip and the spine. She has always been active and eats a well-balanced diet. She takes
calcium supplementation, 500 mg daily, and has done so for the past 3 years, since her last
menstrual period. She has had mild to moderate hot flashes for a year, but these have been
tolerable. Her family history is remarkable for her mother who had postmenopausal breast cancer
diagnosed at age 62 years and a subsequent hip fracture at age 78 years.
She reports some insomnia for which she occasionally uses zolpidem. Her surgical history
includes an appendectomy as a child. She has no allergies. She has no history of coagulation
disorders or venous thrombosis. She does not smoke cigarettes.
On physical examination, blood pressure is 112/74 mm Hg, height is 65 inches, and weight is 170
pounds (BMI = 22.5 kg/m2). Examination findings, including those from examination of the head,
eyes, ears, nose, and throat, are normal, with no masses or adenopathy.
Laboratory test results:
Chemistry panel, normal
25-Hydroxyvitamin D = 38 ng/mL
Total cholesterol = 248 mg/dL
Triglycerides = 111 mg/dL
HDL cholesterol = 27 mg/dL
LDL cholesterol = 169 mg/dL
In considering possible therapeutic options, you discuss the pros and cons of raloxifene.
On the basis of her history, physical examination findings, and laboratory test results, which one
of the following represents a potential area of secondary benefit if you were to institute use of this
medication?
A. BMI
B. Coronary artery disease risk
C. Breast cancer risk
D. Hot flashes
E. Insomnia
Answer: C
Educational objective:
Recognize that selective estrogen receptor modulators have both estrogen agonist and antagonist
actions at multiple target tissues.