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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