Download VRAGEN CALCIUM METABOLISME 3] A 28-year

VRAGEN CALCIUM METABOLISME
3] A 28-year-old woman is evaluated for a serum calcium level of 11.0 mg/dL (2.74 mmol/L)
obtained during a routine physical examination. All other laboratory values are normal. The
parathyroid hormone (PTH) level was subsequently checked and is 40 pg/mL (40 ng/L). The
patient is healthy and has no symptoms of polyuria, constipation, or fatigue. Her mother and
maternal grandfather have a history of hyperparathyroidism, and they both underwent
parathyroidectomy but remained mildly hypercalcemic. The patient had a recent renal
ultrasound that showed no evidence of nephrolithiasis. Her diet is rich in dairy products, and
she has no history of gastrointestinal illness.
Which of the following tests would be most likely to confirm the diagnosis?
A
25-hydroxyvitamin D
B
1,25-dihydroxyvitamin D 3
C
Urine calcium/creatinine clearance ratio
D
Parathyroid hormone–related peptide
E
Prolactin
133] A 75-year-old woman is evaluated after a recent fractured hip. She has a history of
hypertension and hypothyroidism but has not been taking any medications for the past year.
She lives alone and seldom leaves her house. She has a scanty diet and does not consume
dairy products. She does not smoke cigarettes or drink alcohol.
On physical examination, she has moderate dorsal kyphosis, a small firm goiter, and diffuse
muscle weakness. Bone densitometry confirms low bone mass in her spine (T-score −2.9) and
the unaffected hip (T-score −3.4).
Laboratory Studies
Complete blood count
Normal
Calcium
8.6 mg/dL (2.15
mmol/L)
Phosphorus
2.4 mg/dL (0.77
mmol/L)
Alkaline phosphatase
165 U/L
Thyroid-stimulating
hormone
21 µU/mL (21
mU/L)
Which of the following serum tests would be most helpful in determining the cause of this
patient's skeletal disease?
A
Parathyroid hormone
B
25-dihydroxyvitamin D
C
1,25-dihydroxyvitamin D3
D
Osteocalcin
E
Protein electrophoresis
31] A 43-year-old woman with a recent diagnosis of B-cell lymphoma is being evaluated for
chemotherapy. She is hospitalized because of fatigue, dizziness, polyuria, and constipation.
She fell at home while trying to get out of bed. On physical examination, she is orthostatic
and pale. The hematocrit is 38%, blood urea nitrogen 65 mg/dL (23.21 mmol/L), creatinine
2.5 mg/dL (221.05 µmol/L), and calcium 12.8 mg/dL (3.19 mmol/L). Intravenous fluid
resuscitation with normal saline is initiated.
Which of the following is the most appropriate next test in the evaluation of this patient?
A
Parathyroid hormone (PTH)
B
Parathyroid hormone–related peptide (PTHrP)
C
1,25-dihydroxyvitamin D3
D
25-hydroxyvitamin D
40] A 68-year-old man with inoperable squamous cell carcinoma of the lung is hospitalized
for fatigue, weakness, polyuria, anorexia, and a change in mental status. He has lost 11 kg (24
lb) over the past 6 months.
Physical examination shows a lethargic elderly man who is difficult to arouse. Orthostasis,
skin tenting, and decreased breath sounds in the right lower lung base are present. Laboratory
tests show a blood urea nitrogen of 88 mg/dL (31.42 mmol/L), creatinine 2.9 mg/dL (256.42
µmol/L), albumin 2.5 g/dL (25 g/L), and calcium 12.9 mg/dL (3.22 mmol/L). The parathyroid
hormone–related peptide level is elevated. Electrocardiography reveals a shortening of the
QTc interval. Aggressive intravenous hydration with 0.9% sodium chloride is initiated,
followed by furosemide administration to initiate a saline diuresis; 6 hours later the calcium
level is 11.8 mg/dL (2.94 mmol/L) and the patient is responding appropriately to verbal
stimuli.
Which of the following is the most appropriate next step in the management of this patient?
A
Corticosteroids
B
Gallium nitrate
C
Alendronate
D
Plicamycin
E
Intravenous zolendronate
45] A 62-year-old woman is evaluated for mild hypercalcemia. She has a history of
hypertension, type 2 diabetes mellitus, dyslipidemia, diabetic retinopathy, and
hypothyroidism. She does not have polyuria, polydipsia, polyphagia, constipation, fatigue, or
neurocognitive impairment. Medications include glipizide, metformin, atorvastatin,
exetimibe, ramipril, hydrochlorothiazide, and levothyroxine. Physical examination reveals a
blood pressure of 130/90 mm Hg, a pulse rate of 70/min, retinal scars of prior laser therapy, a
40-g goiter, acanthosis nigricans on the back of the neck and in the axilla bilaterally, and a
normal return of the relaxation phase of deep tendon reflexes.
Laboratory Studies
Blood urea nitrogen
25 mg/dL (8.93
mmol/L)
Creatinine
1.2 mg/dL (106.1
µmol/L)
Hemoglobin A1c
7.5%
Albumin
4.0 g/dL (40 g/L)
Calcium
11.0 mg/dL (2.74
mmol/L)
Alkaline phosphatase
110 U/L
Alanine
aminotransferase
25 U/L
Aspartate
aminotransferase
28 U/L
Review of old medical records show that the calcium has been intermittently elevated over the
past 2 years.
Which of the following is the most appropriate next step in the management of this patient?
A
Measure parathyroid hormone
B
Measure thyroid-stimulating hormone (TSH)
C
Stop ramipril
D
Stop hydrochlorothiazide
E
Stop atorvastatin
100] A 25-year-old woman is evaluated for palpitations, diaphoresis, dizziness, and
unintentional weight loss. She feels fatigued and stressed and has a difficult time sleeping at
night. Family history is significant for Hashimoto thyroiditis in her mother. Personal medical
history is noncontributory. Physical examination reveals a blood pressure of 130/78 mm Hg, a
pulse rate of 120/min, bilateral proptosis, a diffusely enlarged goiter, hyperdynamic apical
impulse with tachycardia, tremor of the outstretched hands, and a quick return of the
relaxation phase of deep tendon reflexes.
Laboratory Studies
Complete blood count Normal
Sodium
140 meq/L (140
mmol/L)
Potassium
3.8 meq/L (3.8
mmol/L)
Albumin
4.0 g/dL (40 g/L)
Calcium
11.0 mg/dl (2.74
mmol/L)
Alkaline phosphatase
150 U/L
Thyroid-stimulating
hormone
<0.005 µU/mL
(0.005 mU/L)
Free thyroxine (T4)
3.5 ng/dL (45
pmol/L)
A diagnosis of Graves' disease is made.
Which of the following is the most appropriate next step in the management of this patient's
hypercalcemia?
A
Measure parathyroid hormone
B
Measure 25-hydroxyvitamin D
C
Start calcitonin therapy
D
Start bisphosphonate therapy
E
Re-evaluate after the patient is euthyroid
10] A 48-year-old woman is evaluated for a serum calcium concentration of 11.4 mg/dL (2.84
mmol/L) discovered on routine screening. A dual-energy x-ray absorptiometry showed T
scores at the lumbar spine and left femoral neck of −0.88 and −0.05 respectively. There is no
history or evidence of renal stones, bone fracture, cognitive impairment, or fatigue. The intact
serum parathyroid hormone level is 115 pg/mL (115 ng/L). The serum creatinine is 0.9 mg/dL
(79.58 µmol/L). The urine calcium/creatinine clearance ratio is greater than 0.01, but the 24hour urine calcium excretion is 250 mg (6.3 mmol).
Which of the following is the most appropriate next step in the management of this patient?
A
Observation
B
Intravenous pamidronate
C
Mammography
D
Parathyroidectomy
E
Low-calcium diet
62] A 55-year-old man is evaluated for hypercalcemia. He has a long-standing history of
hypertension, type 2 diabetes mellitus, chronic kidney disease, congestive heart failure, atrial
fibrillation, and a stroke with left residual hemiparesis; 3 months ago he had a right Colles
fracture. Medications include insulin glargine, sevelamer, amlodipine, hydralazine, clonidine,
furosemide, aspirin, simvastatin, calcium carbonate, and calcitriol.
Laboratory Studies
Calcium
12.0 mg/dL (2.99
mmol/L)
Phosphorus
6.0 mg/dL (1.94
mmol/L)
Parathyroid
hormone
1500 pg/mL (1500
ng/L)
Urea nitrogen
70 mg/dL (25 mmol/L)
Creatinine
3.5 mg/dL (309.47
µmol/L)
Radiographs reveal lesions of osteitis fibrosa cystica in the right humerus and left femoral
shaft. Review of old medical records reveals that the serum calcium level was low-normal 5
years ago and has become elevated in the past few years. A thallium sestamibi scan shows
four-gland parathyroid hyperplasia.
Which of the following is the most appropriate therapy for this patient?
A
Parathyroidectomy
B
Alendronate
C
Pamidronate
D
Cinacalcet hydrochloride
E
Calcitonin
95] A 65-year-old man, who is a cigarette smoker, is evaluated for blurry vision. Six months
ago he was treated with radioactive iodine for hyperthyroidism resulting from Graves' disease.
He subsequently became hypothyroid, requiring thyroid hormone replacement therapy.
Recently the patient has noticed bilateral eye irritation manifested by tearing, injected painful
sclerae, and periorbital swelling, and his wife says his eyes are “bulging.” Over the past 2
weeks the patient has a rapidly decreased visual acuity which does not clear with blinking.
Physical examination reveals periorbital edema and scleral injection. Eye movements are
notable for pain with upward gaze, bilateral proptosis, and an afferent pupillary defect on the
left. Snellen chart testing shows 20/20 vision on the right but 20/200 on the left.
Which of the following is the most likely cause of this patient's decreased visual acuity?
A
Exposure keratitis
B
Optic nerve impingement
C
Strabismus
D
Corneal abrasions
E
Recurrent thyrotoxicosis
118] A 30-year-old woman is found to have asymptomatic hypercalcemia on a routine
physical examination. She notes having an occasional milky discharge from her breasts. Her
menses have been irregular for the past year. Both her mother and her sister have been
previously diagnosed with pituitary tumors, and hypercalcemia. Her estimated oral calcium
intake is 600 mg/d. On physical examination, she has expressible galactorrhea. Funduscopic
examination and visual field testing are normal to confrontation.
Laboratory Studies
Calcium
11.2 mg/dL (2.79
mmol/L)
Phosphorus
2.5 mg/dL (0.81
mmol/L)
Chloride
109 meq/L (109
mmol/L)
Albumin
4.8 g/dL (48 g/L)
Intact parathyroid
hormone
55 pg/mL (55 ng/L)
Prolactin
142 ng/mL (142
mg/L)
Which of the following therapies is most likely to correct the patient's hypercalcemia?
A
An oral bisphosphonate
B
Surgery to remove a parathyroid adenoma
C
Surgery to remove a pheochromocytoma
D
Surgery to remove 3½ parathyroid glands
E
Surgery to remove a pituitary tumor
94] A 44-year-old man is evaluated for flushing, palpitations, and intermittent diarrhea of 18
months' duration. Physical examination reveals hepatomegaly and dermatographism. The
results of a comprehensive metabolic profile are normal, other than a calcium level of 11.8
mg/dL (2.94 mmol/L). Parathyroid hormone is undetectable.
Which of the following would be the most appropriate next test in the evaluation of this
patient?
A
Bone scan
B
Parathyroid hormone–related peptide
C
Bone-active cytokines
D
1,25-dihydroxyvitamin D3
139] A 66-year-old woman is evaluated for malaise and confusion. She has smoked 1 pack of
cigarettes a day for the past 40 years. She takes hydrochlorothiazide for hypertension.
Physical examination reveals distant breath sounds. Chest radiograph shows a 1.5-cm mass in
the proximal upper lobe of the left lung and infiltrates distal to the mass. A bone scan
indicates no evidence of focal or metastatic disease.
Laboratory Studies
Calcium
15.8 mg/dL (3.94
mmol/L)
Phosphorus
4.0 mg/dL (1.29
mmol/L)
Chloride
97 meq/L (97
mmol/L)
Intact parathyroid
hormone
<1.0 pg/mL (1.0
ng/L)
Serum protein electrophoresis shows polyclonal gammopathy.
Which of the following is the most likely cause of the patient's hypercalcemia?
A
Thiazide-induced hypercalcemia
B
Parathyroid adenoma
C
Parathyroid hyperplasia
D
Humoral hypercalcemia of malignancy
E
Multiple myeloma