Medical quiz 1.

This is the first in a series of monthly quizzes to get both C.O and volunteer drs thinking. This is based on a real life patient I treated.

Feel free to post your comments.

Answers in 2 weeks.

Quiz 1.

73 year old patient with a long term history of osteoporosis and spinal stenosis presents with worsening pelvis pain and difficulty walking. She has no history of trauma.

Regular medications:

Paracetamol and codeine for pain

Alendronic acid and calcium and vitamin D for osteoporosis

O/E she is tender on palpation of her pelvis and walk with an antalgic gait (painful walk).

I refer her for an X-ray

 

What does the X ray show?

Blood tests are vitamin D 76 (>50 normal), Ca 2.8 (2.2-2.6) and PTH 13.4 (1.6-7.2)

What is her diagnosis?

Is this primary or secondary?

What is the commonest cause and how do you treat it?

What are the complications of this treatment?

If this treatment isn’t available how can you manage the patient?

 

 

 

2 thoughts on “Medical quiz 1.”

  1. Here are the answers:
    What does the X ray show?
    Pubic rami fracture
    Blood tests are vitamin D 76 (>50 normal), Ca 2.8 (2.2-2.6) and PTH 13.4 (1.6-7.2)
    What is her diagnosis?
    Hyperparathyroidism
    Is this primary or secondary?
    Primary (PHP). Primary hyperparathyroidism (PHP) is common, especially in women aged over 65 years. It is present in up to 1 in 500 of the general population.

    Criteria for the diagnosis of PHP1
    • Adjusted calcium >2.65mmol/L on two separate samples.
    • Normal renal function (may be abnormal if adjusted Calcium >3mmol/L).
    • PTH >3pmol/L.
    • Urinary calcium >2.5mmol/24 hours.
    • Patient not taking thiazide diuretic or lithium.

    What is the commonest cause and how do you treat it?
    PHP is caused by a solitary parathyroid adenoma in 85 per cent of cases.
    The condition is treatable with surgery.
    (Prior to surgery, the patient requires an ultrasound scan of the neck and 99mTc-sestamibi scan to localise the parathyroid glands and any tumours. Those with parathyroid hyperplasia are offered a partial parathyroidectomy. Those with a pre-operatively localised parathyroid adenoma are offered minimally invasive surgery. )
    What are the complications of this treatment?
    Complications associated with parathyroid surgery are rare but include vocal cord paresis and hypocalcaemia.
    Following a total parathyroidectomy, the post-operative hypocalcaemia is permanent and requires lifelong oral calcium and vitamin D supplementation.
    Following a partial parathyroidectomy or parathyroid adenomectomy, the hypocalcaemia is transient as the remaining normal parathyroid tissue recovers.
    If this treatment isn’t available how can you manage the patient?

    For patients who do not meet the criteria for surgery, monitoring alone is suitable. These patients require annual plasma calcium and renal function plus two yearly DEXA and renal ultrasound scans. Two to 3 per cent of these patients per annum will develop new indications for surgery, so follow up is important.
    These patients should be advised to maintain adequate hydration. Thiazide diuretics and lithium should be avoided.

     

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