Thanks to Ian Hainsworth for suggesting this Case.
A 75 year old man, seeing his Family Doctor. Clinical information is
'Parathyroidectomy 1997. Annual check'.
Serum results are
Sodium: 139 mmol/L (135 - 145)
Potassium: 4.8 mmol/L (3.5 - 5.3)
Bicarbonate: 13 mmol/L (20 - 35)
Urea: 16.6 mmol/L (2.5 - 7.5)
Creatinine: 428 umol/L (70 - 135)
Adjusted calcium: 2.59 mmol/L (2.15 - 2.60)
Phosphate: 1.2 mmol/L (0.8 - 1.4)
Parathyroid hormone: 420 ug/L (<50)
This Case attracted 41 participants, and an interesting range of opinion.
There was some difference of opinion between the assessors, indicated by
asterisks below. I
should probably have given more details about this Case, since 5
participants queried what type of PTH assay it was, 1 commenting
'impossible to comment without knowing the type', 3 wanted more information
about the type of parathyroidectomy, and 2 wanted to know the albumin
concentration.
12 participants would contact the Family Doctor to discuss these results
(1.8)
18 commented renal impairment or renal failure; (1.8)
9 pointed out the metabolic acidosis; (1.3)
1 suggested renal tubular acidosis. (-0.3)
11 said that the PTH was inappropriately high; (1.8)
3 querying a recurrence of hyperparathyroidism; (1.5)
8 suggested persisting or recurrence of primary hyperparathyroidism; (1.0)
4 queried secondary hyperparathyroidism; (1.3)
6 queried tertiary hyperparathyroidism, (0.0*)
2 adding 'if renal disease is long-standing'; (0.8)
4 queried primary or secondary to renal disease; (1.3)
2 queried primary or tertiary; (0.8)
4 queried secondary or tertiary. (1.0)
1 queried interference in the PTH assay. (0.5)
2 would check this PTH value; (1.3)
3 would measure PTH by a different assay system. (1.3)
3 would measure ionized calcium; (0.0)
2 would measure chloride and calculate an anion gap; (-0.5)
2 would suggest a neck examination; (-1.0)
1 each would measure/ suggest measuring
glucose (-0.8)
urine calcium and phosphate (0.8)
alkaline phosphatase; (1.3)
creatinine clearance. (-1.5)
2 suggested urgent hospital referral; (-0.3)
7 would suggest referral to the nephrologist; (1.5)
1 would suggest referral to the surgeon; (0.0*)
1 would suggest referral to the endocrinologist. (1.0)
Ian discovered that the patient was treated for a malignant bladder tumour
in 1987. He subsequently developed hypercalcaemia and deteriorating renal
function, and in 1997 a parathyroid adenoma was removed. Ian's comment was
'Increased PTH. The serum calcium is not proportionally increased but this
is probably due to acidosis consequent on renal failure. A high ionized
calcium may be expected. Consistent with recurrence of primary
hyperparathyroidism' (which I would score as 5.9 on the Richter scale).
More email problems, in that my Internet server this week permanently
deleted all the emails in my Inbox. If any of you are expecting a reply
from me about something, please send me the message again and I will do my
best.
Best wishes
Gordon Challand
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