Tutorial 7 - Bone Disorders Flashcards
(12 cards)
CASE STUDY 1
55 year old South Asian gentleman presented to his GP with aches and pains.
On examination he had evidence of proximal myopathy.
His GP checked some blood tests:
- normal renal function
- serum calcium 2.10 (reference range 2.15 – 2.60 mmol/L)
- serum phosphate 0.8 (reference range: 0.80 – 1.40 mmol/L)
- 25 hydroxyvitamin D 10 (reference range : 70 – 150 nmol/L)
- PTH 20 (reference range: 1.1 – 6.8 pmol/L).
What is the diagnosis?
CASE 1
- Vitamin D deficiency (osteomalacia) and secondary hyperparathyroidism
- Proximal myopathy, low vitamin D, high PTH (calcium is normal so PTH can still liberate enough calcium from the bone as to keep calcium normal but calcitriol cannot help). Falling calcium raises the PTH. DEXA scan shows the low BMD
What risk factors do he have for developing this?
CASE 1
Patient is older, of south-Asian descent and may not be in the sun enough.
Note –most people do NOT get enough sun
Why is the PTH elevated?
CASE 1
As calcium drops due to low calcitriol, PTH raises to correct the falling calcium
What treatment should be offered?
CASE 1
Normal renal function –Ergocalciferol or cholecalciferol
Impaired renal function –Alfacalcidol
CASE STUDY 2
A 55 year old South Asian gentleman presented to his GP with loin pain, which was worse on passing urine.
His GP detected microscopic haematuria on a urine dipstick.
His GP checked some blood tests:
- normal renal function
- serum calcium 2.90 (reference range: 2.15 – 2.60 mmol/L )
- serum phosphate 0.6 (reference range: 0.80 – 1.40 mmol/L)
- 25 hydroxyvitamin D 84 (reference range: 70 – 150 nmol/L)
- PTH 12 (reference range: 1.1 – 6.8 pmol/L).
What is the diagnosis?
CASE 2
- Primary hyperparathyroidism –high PTH, high calcium, low phosphate
- Tumour of the parathyroid gland and possible problem in kidneys
What is the cause of his loin pain?
CASE 2
Kidney stones due to extra-skeletal calcification
How should he be treated?
CASE 2
Drink to dilute the blood, ultrasound to detect adenoma of parathyroid and surgery to correct.
If the patient is young, could’ve’ been MEN-T1 –Multiple Endocrine Neoplasia, which has a genetic base and has a different treatment plan (cut it out and it grows back).
CASE STUDY 3
A 51-year-old woman comes to her GP’s surgery.
She is tired, with aches and pains all over her body for several months.
She feels low in mood.
She has noticed that she has become more constipated previously.
Her GP checks some blood tests:
- normal renal function
- serum calcium 2.80 (reference range: 2.15 – 2.60 mmol/L )
- serum phosphate 1.00 (reference range: 0.80 -1.40 mmol/L)
- 25 hydroxyvitamin D 70 (reference range: 70 – 150 nmol/L)
- PTH <1.1 (reference range: 1.1 – 6.8 pmol/L).
She had a left mastectomy and adjuvant radiotherapy for breast cancer 3 years ago.
What is the most likely diagnosis?
CASE 3
Malignancy secreting PTH-RP causing hypercalcaemia
How should be they treated?
CASE 3
Fluids via oral or IV route.
Give bisphosphonates.
