WBR0268

Author	PageAuthor::Vendhan Ramanujam
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Community Medical Health Center, MainCategory::Primary Care Office, MainCategory::Inpatient Facilities
Sub Category	SubCategory::Endocrine, SubCategory::Electrolytes
Prompt	[[Prompt::A 60 year old asymptomatic white female comes to the physicians office for a routine physical examination. Her routine lab test shows Sodium: 138 mEq/L Potassium: 3.8 mEq/L Bicarbonate: 26 mEq/L Chloride: 101 mEq/L Calcium: 12 mg/dL Albumin: 4.0 g/dL Phosphorus: 2.2 mg/dL PTH level is increased. Bone mineral density by dual energy X-ray absorptiometry (DEXA) shows T-2.5 bone mineral density 5 at lumbar spine and femoral neck. Neck examination reveals no mass. What is the most appropriate step in management of this patient?]]
Answer A	AnswerA::Thiazide diuretics
Answer A Explanation	[[AnswerAExp::Incorrect-Thiazide diuretics will worsen hypercalcemia and thus they are avoided.]]
Answer B	AnswerB::Loop diuretics
Answer B Explanation	[[AnswerBExp::Incorrect-Loop diuretics are used for symptomatic primary hyperparathyroid patients.]]
Answer C	AnswerC::Routine neck and serum chemistry surveillance
Answer C Explanation	AnswerCExp::'''Incorrect'''-Routine neck and serum chemistry surveillance is appropriate only in patients with asymptomatic primary hyperparathyroidism without any of the above-mentioned features.
Answer D	AnswerD::Bisphosphonate therapy
Answer D Explanation	[[AnswerDExp::Incorrect-Bisphosphonate therapy might be useful to improve the bone mineral density and in patients who refuse surgery to prevent a fall in BMD. But their long term use benefits and risks in primary hyperparathyroidism are unknown.]]
Answer E	AnswerE::'''Correct'''-Surgical exploration of the neck
Answer E Explanation	[[AnswerEExp::Correct-The patient is presenting with asymptomatic primary hyperparathyroidism. The laboratory diagnosis of hypercalcemia, hypophosphatemia and elevated serum PTH hormones, suggest primary hyperparathyroidism. Asymptomatic primary hyperparathyroidism is a common disorder particularly in females above 60 years of age who are usually diagnosed during a routine chemistry screening. While patients with symptomatic primary hyperparathyroidism require surgical intervention, not all patients with asymptomatic primary hyperparathyroidism except those with at least one of the following features would require a surgical intervention. 1.Age less than 50 years 2.Serum calcium at least 1 mg/dL above the upper limit of normal 3.Bone mineral density (BMD) lower than T-2.5 at lumbar spine, femoral neck, total hip, or 33% (one third) radius This patient has two of the above features i.e. serum calcium 1 mg/dL above the upper limit of normal and DEXA scan showing BMD lower than T-2.5 at lumbar spine and femoral neck. Thus surgical intervention is indicated in this patient.]]
Right Answer	RightAnswer::E
Explanation	[[Explanation::The patient is presenting with asymptomatic primary hyperparathyroidism. The laboratory diagnosis of hypercalcemia, hypophosphatemia and elevated serum PTH hormones, suggest primary hyperparathyroidism. Asymptomatic primary hyperparathyroidism is a common disorder particularly in females above 60 years of age who are usually diagnosed during a routine chemistry screening. While patients with symptomatic primary hyperparathyroidism require surgical intervention, not all patients with asymptomatic primary hyperparathyroidism except those with at least one of the following features would require a surgical intervention. 1.Age less than 50 years 2.Serum calcium at least 1 mg/dL above the upper limit of normal 3.Bone mineral density (BMD) lower than T-2.5 at lumbar spine, femoral neck, total hip, or 33% (one third) radius This patient has two of the above features i.e. serum calcium 1 mg/dL above the upper limit of normal and DEXA scan showing BMD lower than T-2.5 at lumbar spine and femoral neck. Thus surgical intervention is indicated in this patient. Educational Objective: Asymptomatic primary hyperparathyroidism patients presenting with at least one of the following features would require a surgical intervention. 1.Age less than 50 years 2.Serum calcium at least 1 mg/dL above the upper limit of normal 3.Bone mineral density (BMD) lower than T-2.5 at lumbar spine, femoral neck, total hip, or 33% (one third) radius Hypercalciuria and reduced GFR are no longer considered as criteria for surgery in asymptomatic primary hyperparathyroidism patients. Educational Objective: References: ]]
Approved	Approved::Yes
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