CM3: Endocrine Patient Vignettes - Parathryoid
A T score of __________ would be considered low bone mass (osteopenia). A. > -1 B. -1 to -2.5 C. < -2.5 D. < -2.5 and a history of one or more osteoporotic fracture
-1 to -2.5
A bone mineral density test giving a T-score of less than or equal to ________ is diagnostic of osteoporosis. A. -1.0 B. -1.5 C. -2.0 D. -2.5
-2.5
For most older patients the USPSTF recommends calcium and a vitamin D supplement of _______ IU daily for prevention of osteoporosis. A. 500 B. 1000 C. 1500 D. 2000 E. 2500
2000
What is the most stable assay for testing vitamin D level in the blood? A. D2 ergocalciferol B. D3 cholecaliferol C. Calcitriol D. 25 Hydroxy Vitamin D E. 1,25 (OH)2 Vitamin D
25 Hydroxy Vitamin D
A T score of __________ would be considered diagnostic of osteoporosis. A. > -1 B. -1 to -2.5 C. < -2.5 D. < -2.5 and a history of one or more osteoporotic fracture
< -2.5
A T score of __________ would be considered diagnostic of severe osteoporosis. A. > -1 B. -1 to -2.5 C. < -2.5 D. < -2.5 and a history of one or more osteoporotic fracture
< -2.5 and a history of one or more osteoporotic fracture
A T score of __________ would be considered normal. A. > -1 B. -1 to -2.5 C. < -2.5 D. < -2.5 and a history of one or more osteoporotic fracture
> -1
A 51-year-old female presents to her primary care physician complaining of body aches and constipation. She reports that her "bones hurt" and that she has experienced worsening constipation over the past few months. Her medical history is notable for three kidney stones within the past year that both passed spontaneously. Her vital signs are stable. Physical examination reveals a small nodule near the right inferior pole of the thyroid. Which of the following sets of serum findings is most likely in this patient? A. Increased calcium, decreased phosphate, increased parathyroid hormone B. Decreased calcium, increased phosphate, increased parathyroid hormone C. Increased calcium, decreased phosphate, decreased parathyroid hormone D. Decreased calcium, decreased phosphate, increased parathyroid hormone E Normal calcium, normal phosphate, normal parathyroid hormone
A. Increased calcium, decreased phosphate, increased parathyroid hormone The most likely diagnosis in this patient is primary hyperparathyroidism due to a parathyroid adenoma. In primary hyperparathyroidism, parathyroid hormone (PTH) is increased, calcium is increased, and phosphate is decreased. The presence of bony aches, constipation, and kidney stones is suggestive of symptomatic hypercalcemia, which is characterized by "bones, groans (constipation), stones, and psychiatric overtones." Furthermore, the presence of a mass in the inferior pole of the thyroid suggests that this patient's metabolic abnormalities may stem from a parathyroid adenoma secreting excess PTH. Parathyroid hormone functions to increase serum calcium and decrease serum phosphate in response to hypocalcemia or hypomagnesemia. This is accomplished by increasing bone resorption, increasing kidney resorption of calcium, decreasing kidney resorption of phosphate, and increasing production of 1,25-hydroxyvitamin D. In cases of primary hyperparathyroidism, PTH secretion is abnormally high, leading to elevated serum calcium and decreased serum phosphate.
A 59-year-old Caucasian female suffered a fracture of her left distal radius after she lost her balance while reaching overhead and fell from standing height. A follow-up DEXA bone density scan is performed and demonstrates a T-score of -3.5 at the femoral neck and spine. Her medical history is significant for venous thromboembolic disease; she has not had a previous fracture. After open reduction and internal fixation is achieved, which of the following is the best treatment to mitigate this patient's risk of future fragility fractures? A. Raloxifene B. Activity limitation C. Alendronate in combination with calcium and vitamin D supplementation D. Risedronate alone E. Intranasal calcitonin
Alendronate in combination with calcium and vitamin D supplementation This patient has osteoporosis (T score less than 2.5) and experienced a fragility fracture of the left wrist. Osteoporotic patients who suffer a fragility fracture should be treated with calcium and vitamin D supplementation as well as alendronate to increase/maintain bone density and lower the risk of future fractures.
Which of the following is a bisphoshonate drug? (2) A. Alendronate B. Raloxifene C. Teriparatide D. Denosumab E. Zolendronic Acid
Alendronate; Zolendronic Acid (3rd gen)
________________ are a type of medication used in osteoporosis, hypercalcemia and Paget disease of bone as they bind hydroxyapatite in bone, inducing apoptosis in osteoclasts.
Bisphosphonates
A 67-year-old Caucasian female presents to her primary care physician after a screening DEXA scan reveals a T-score of -3.0. Laboratory work-up reveals normal serum calcium, phosphate, vitamin D, and PTH levels. She smokes 1-2 cigarettes per day. Which of the following measures would have reduced this patient's risk of developing osteoporosis? A. Reduced physical activity to decrease the chance of a fall B. Initiating a swimming exercise program three days per week C. Intranasal calcitonin therapy D. Calcium and vitamin D supplementation E. Weight loss
Calcium and vitamin D supplementation This patient with a DEXA T-score of less than -2.5 has osteoporosis. Interventions that decrease the risk of osteoporosis include: smoking cessation, a weight-bearing exercise regimen, vitamin D and calcium supplementation, or hormone replacement therapy.
__________________ is a physical exam sign which is related to hypocalcemia; it involves contraction of the facial muscles upon tapping of the cheek.
Chvostek sign
A 44-year-old caucasian male complains of carpopedal spasms, peri-oral numbness, and paresthesias of the hands and feet. His wife also mentions that he had a seizure not too long ago. His past surgical history is significant for total thyroidectomy due to papillary thyroid carcinoma. They then realized all of the symptoms occurred after the surgery. Which of the following would be present in this patient? A. Chvostek sign, QT prolongation, increased PTH, decreased serum calcium, decreased serum phosphate B. Chvostek sign, QT prolongation, decreased PTH, increased serum calcium, decreased serum phosphate C. Chvostek sign, QT shortening, increased PTH, increased serum calcium, increased serum phosphate D. Chvostek sign, QT prolongation, decreased PTH, decreased serum calcium, increased serum phosphate E. Chvostek sign, QT shortening, decreased PTH, decreased serum calcium, increased serum phosphate
Chvostek sign, QT prolongation, decreased PTH, decreased serum calcium, increased serum phosphate The patient's neurologic involvement after total thyroidectomy is highly suggestive of primary hypoparathyroidism.
A 71-year-old man comes to the office because of non-radiating lower back pain for the past 5 months. He states that the pain has come on very slowly. He took ibuprofen, which helped initially, but it has since become much worse. He cannot remember any back trauma and does no heavy lifting. He mentions feeling shorter than he was previously and physical exam shows a decrease in height of 3 inches and tenderness over L1. Examination shows a slight abnormal curve of the spine. Radiographic studies show anterior vertebral wedging and vertebral end-plate irregularity. What is the most likely underlying pathology? A. Decreased osteoblast activity, normal osteoclast activity B. Increased osteoblast activity, decreased osteoclast activity C. Intervertebral disc degeneration D. Intervertebral disc space calcification E. Decreased osteoblast activity, increased osteoclast activity
Decreased osteoblast activity, normal osteoclast activity Osteoporosis type 2 ('senile osteoporosis'), occurs in patients over 60 of both genders. It is characterized by decreased osteoblast activity with normal osteoclast activity that will result in decreased bone density overall, which increases the risk of fracture.
Which of the following is not a bisphosphonate drug? A. Alendronate B. Risedronate C. Boniva D. Denosumab E. Zolendronic Acid
Denosumab
______________ is a monoclonal antibody used to treat osteoporosis by binding to RANKL, inhibiting osteoclast maturation as a osteoprotegerin mimic. A. Alendronate B. Raloxifene C. Teriparatide D. Denosumab E. Zolendronic Acid
Denosumab
A 65-year-old woman comes to the office for a yearly physical examination. She states that she has been well in the past year and has no current concerns. Her medical history includes well controlled type II diabetes mellitus, depression, and hypertension. She currently takes metformin, fluoxetine, and hydrochlorothiazide. She is up-to-date with age appropriate screening tests that were recommended at prior physical examinations. During her current visit, which of the following screening investigations is most appropriate to discuss? A. Colonoscopy B. Dual-energy X-ray absorptiometry scan C. Mammogram D. Pap smear E. Sigmoidoscopy
Dual-energy X-ray absorptiometry scan Osteoporosis screening in women should begin at age 65. Dual-energy X-ray absorptiometry (DEXA) testing is the most widely used method for screening. Routine screening for men with no known risk factors has not been recommended.
A 68-year-old woman undergoes a dual-energy X-ray absorptiometry scan to assess bone mineral density. Which of the following is not a risk factor for the development of osteoporosis? A. Alcohol use B. Steroid use C. Elevated BMI D.Smoking E. Sedentary lifestyle
Elevated BMI
A 67-year-old male presents to his primary care physician complaining of left hip pain for the past six months. He denies any trauma or recent falls. He is accompanied by his wife who reports that he has experienced progressive hearing loss over the same time period. The patient has also noticed that he is no longer able to fit into his favorite hat even though it previously fit well. . Which of the following laboratory abnormalities is most likely to be found in this patient? A. Elevated serum parathyroid hormone B. Elevated serum calcium C. Decreased serum calcium D. Elevated serum alkaline phosphatase E. Decreased serum alkaline phosphatase
Elevated serum alkaline phosphatase The most likely diagnosis for this patient is Paget's bone disease. This disease is associated with an isolated elevation in serum alkaline phosphatase with normal serum calcium, phosphate, and parathyroid hormone levels.
The drug class __________________ can cause osteoporosis by decreasing calcium absorption from the gastrointestinal tract through antagonism of calcitriol.
Glucocorticoids
_____________ is a common complication of Paget disease of bone due to narrowing of the auditory foramen.
Hearing loss
(Hypercalcemia/Hypocalcemia) is a main feature of primary hyperparathyroidism.
Hypercalcemia
A 55-year-old female presents to her family physician with pain in the fingers of her right hand. She is mildly confused and is unsure exactly how long she has had this pain. The patient's daughter, who accompanied her mother to the visit, says that the patient has complained about this pain for about a month and has been progressively more confused over the last week. She also says that her mother has been complaining of increased nausea for the last few months. An X-ray of the right hand shows thin bones with brown tumors. Based on the patient's history and symptoms, what is the most likely cause of her condition? A. Hypocalcemia B. Osteoporosis C. Hyperparathyroidism D. Osteosarcoma E. Multiple myeloma
Hyperparathyroidism often leads to hypercalcemia, which can result in bone pain, kidney stones, gastrointestinal disturbances, and psychiatric changes. Osteitis fibrosa cystica is a rare manifestation in severe cases that is characterized by the appearance of brown tumors on X-ray. This patient presents with bone pain, nausea, and confusion, which can be seen together in hypercalcemia secondary to hyperparathyroidism. Parathyroid hormone can cause hypercalcemia by stimulating osteoclasts to increase bone resorption as well as an increasing vitamin D activation in the kidney. Common symptoms of hypercalcemia include nausea and confusion, as seen in this patient. In severe hyperparathyroidism, patients may also develop osteitis fibrosacystica (OFC), or "brown tumors" that form in the bones of patients leading to increased risk of fracture. These lesions are cysts filled with blood, fibrous tissue, and osteoclasts. Treatment of OFC can include either intravenous vitamin D or removal of the enlarged parathyroid glands (parathyroidectomy).
(Hypercalcemia / Hypocalcemia) of chronic kidney disease is the most important association of secondary hyperparathyroidism.
Hypocalcemia
A 46-year-old woman comes to the emergency room complaining of difficulty breathing, paresthesias, and anxiety. Upon further questioning, she says that she had a "neck surgery" two days prior following a visit to her primary care physician, who had identified an immobile mass. Her ECG tracing shows a QTc-interval of 500 ms. What is the electrolyte disturbance seen in this patient? A. Hypercalcemia B. Hyperkalemia C. Hypocalcemia D. Hypokalemia E. Hyponatremia
Hypocalcemia
A 41-year-old woman undergoes a thyroidectomy for removal of a malignant growth. Shortly after the surgery she complains of muscle cramps and is noted to have a twitch in her cheek when the facial nerve is tapped. Which of the following is the most likely cause of her symptoms? A. Hyperkalemia due to kidney failure B. Hypervitaminosis D due to hyperparathyroidism C. Hypocalcemia due to hypoparathyroidism D. Hypocalcemia due to hypothyroidism E. Hyponatremia due to adrenal insufficiency
Hypocalcemia due to hypoparathyroidism
(Decreased/Increased) parathyroid hormone, alkaline phosphatase, and cyclic adenosine monophosphate in urine are seen in primary hyperparathyroidism.
Increased
A 74-year-old woman comes to the emergency department because of altered mental status. Her past medical history includes uncontrolled hypertension and type 2 diabetes mellitus. Her last recorded glomerular filtration reveals chronic kidney disease. A radiograph of the patient's hands shows thinning of the phalanges. Routine blood work is performed. Which of the following series of findings is most likely for this patient? A. Increased PTH, decreased calcium, increased phosphate B. Increased PTH, decreased calcium, decreased phosphate C. Increased PTH, increased calcium, decreased phosphate D. Increased PTH, increased calcium, increased phosphate E. Normal PTH, increased calcium, normal phosphate
Increased PTH, decreased calcium, increased phosphate Secondary hyperparathyroidism is characterized by elevated parathyroid hormone (PTH), low serum calcium, and elevated serum phosphate; these are primarily due to hyperphosphatemia and vitamin D deficiency and resistance. Patients with chronic kidney disease are susceptible to secondary hyperparathyroidism.
A 56-year-old woman is in the ER after a seizure. Although suffering from some continued confusion, she keeps pointing at the area around her mouth and saying that it feels "funny." Her husband states that she has a history of osteoarthritis and thyroid cancer, for which she underwent a total thyroidectomy one month ago. As far as he knows, she has no family history of epilepsy. Her exam is notable for 3+ reflexes in her upper and lower extremities. After applying a blood pressure cuff to her arm for 3 minutes, her hand muscles begin to spasm and curl up to her wrist. Which laboratory abnormality is her blood work most likely to reveal? A. Low phosphorous B. Low ionized calcium C. Low magnesium D. High 25-hydroxyvitamin D E. High PTH
Low ionized calcium A post-thyroidectomy patient presenting with seizure, circumoral paresthesias, hyperreflexia, and carpopedal spasm (Trousseau's sign) most likely has hypoparathyroidism, which causes low ionized calcium.
A 16-year-old girl comes to the emergency department because of a panic attack. She began feeling tingling around her mouth and then became nervous at this symptom, causing her to hyperventilate. The tingling has persisted, and she also reports having had muscle cramps and spasms for the past week. A metabolic panel reveals normal electrolytes except for a low serum calcium. A review of the patient's chart reveals thyroid surgery one month earlier due to a suspicious nodule. Which of the following findings is most likely to also be present in this patient? A.Low parathyroid hormone B. Low thyroid-stimulating hormone (TSH) C. High calcitonin D. High parathyroid hormone E. High thyroxine
Low parathyroid hormone Hypoparathyroidism refers to a decrease in parathyroid hormone (PTH) levels and is a possible complication of thyroid surgery due to destruction of the parathyroid glands. The low PTH levels can also lead to hypocalcemia, which may manifest as muscle cramps, spasms, and tetany.
A 65-year-old man to comes to the office because of deep, dull pain in his hip that is constant throughout the day and sometimes worse at night. He says that he has also increased in shoe size in the recent years, and has progressively lost hearing from both ears. Medical history includes admission for a renal calculus one month ago. An X-ray is obtained. Laboratory investigations show an isolated increase in alkaline phosphate. Which of the following pathologies is most often associated with the disease the patient most likely has? A. Giant cell tumor B. Metastatic bone tumors C. Osteoporosis D. Osteosarcoma E. Rickets
Osteosarcoma Paget's disease of the bone has common complications of high-output cardiac failure (due to AV shunts in bone), and osteosarcoma. It is characterized by bone pain due to microfractures, increasing shoe size, hearing loss due to cranial nerve impingement, facial changes, bowing of the tibia, and isolated increased alkaline phosphatase.
_____________ of bone is the most common cause of isolated elevated alkaline phosphatase in patients over 40 years old.
Paget disease
______________ of bone is characterized by an idiopathic imbalance between osteoclast and osteoblast function.
Paget disease
A 60-year-old woman comes to the clinic because of pain in her right thigh and hip. The pain started approximately 5 months ago and is a "deep ache" that worsens on weight bearing. Her husband, who is with her today, also says that "she can't hear a darn thing anymore." Physical examination shows increased warmth over the right thigh. Pertinent laboratory abnormalities include an elevated alkaline phosphatase. Serum calcium and phosphate is normal. Pelvic X-ray shows areas with excessive osteoblastic activity as well as osteolytic lesions. Which of the following is the most likely diagnosis? A. Paget disease B. Hypoparathyroidism C. Multiple myeloma D. Osteomalacia E. Osteopetrosis
Paget disease of bone is caused by osteoclast abnormalities, resulting in this fairly common finding in older patients. It can be identified by an isolated elevated serum alkaline phosphatase as well as the combination of osteolytic and osteoblastic lesions.
A 58-year-old woman comes to the emergency room because of of hip pain, fatigue, and nausea. Physical examination shows joint swelling and tenderness in multiple metacarpal and inter-phalangeal joints, and an X-ray shows diffuse osteoporosis and selective cortical bone loss. A metabolic panel also shows a markedly elevated serum calcium level and ultrasound reveals an abnormally large parathyroid gland on the patient's right side. Which of the following laboratory values would also be expected in this case? A. Decreased serum calcitriol B. Hyperglycemia C. Hypochloremia D. Phosphaturia E. Proteinuria
Phosphaturia This patient has primary hyperparathyroidism, an excess of parathyroid hormone caused by overactivity of the parathyroid glands. This increase in parathyroid hormone often leads to hypercalcemia due to its effects on the bones and kidney. In the bones, parathyroid hormone stimulates osteoclasts to increase bone resorption, while in the kidneys, it activates vitamin D, which then increases calcium resorption in the digestive tract. In the kidneys, parathyroid hormone also acts to reduce the reabsorption of phosphate from the proximal tubules, leading to an increase in the excretion of phosphate in the urine. In the serum, however, phosphate levels are still normal in approximately 50% of patients due to the effects of parathyroid hormone on the uptake of phosphate from the intestine and bones into the blood.
(Primary / Secondary) hyperparathyroidism will have high calcium and low phosphate.
Primary
A 67-year-old man presents to the emergency room after a sudden onset of sharp, intense wrist and forearm pain. The pain began earlier that morning after the patient hit his arm on a railing. An X-ray confirms a small hairline fracture of the distal ulna. The patient appears surprised, stating that the injury seemed minor at the time. Relevant blood labs include: Alkaline phosphatase: 98 U/L Serum calcium: 11.6 mg/dL (Norm: 8.5-10.5) Serum phosphate: 2.1 mg/dL (Norm: 2.5 to 4.5 mg/dL) Based on the patient's history and lab results, what is the most likely diagnosis? A. Osteoporosis B. Paget's disease of bone C. Primary hyperparathyroidism D. Renal insufficiency E. Vitamin D deficiency
Primary hyperparathyroidism In primary hyperparathyroidism, the over-secretion of PTH by the parathyroid glands would likely result in an increase in serum calcium and a decrease in serum phosphate due to its effects on the bones and kidneys, respectively. Main Explanation Primary hyperparathyroidism is a condition characterized by an abnormal increase in parathyroid hormone (PTH) levels due to overactive parathyroid glands. Normally, PTH serves to increase blood calcium levels by acting on the parathyroid hormone 1 receptor in the bone and kidneys, as well as the parathyroid hormone 2 receptor in the central nervous system, pancreas, testis, and placenta. In primary hyperparathyroidism, the over-secretion of PTH by the parathyroid glands stimulates bone resorption to increase blood calcium levels, which can lead to bone weakness and fractures, as seen in this patient. In addition to its effects on bone, PTH also inhibits phosphate reabsorption in the kidneys. Thus, lab results for a patient with primary hyperparathyroidism would likely show elevated calcium levels and decreased phosphate levels. Alkaline phosphatase, which among many things is a byproduct of bone formation, would likely be either elevated or normal in a patient with primary hyperparathyroidism.
Hypoparathyroidism can present with __________________ on ECG.
QT prolongation
Which of the following is osteoporosis medications in creases a patients risk of thromboembolism and hot flashes? A. Alendronate B. Raloxifene C. Boniva D. Denosumab E. Zolendronic Acid
Raloxifene
Which of the following is osteoporosis medications is a selective estrogen receptor modulator and can reduce vertebral fractures by 40? A. Alendronate B. Raloxifene C. Boniva D. Denosumab E. Zolendronic Acid
Raloxifene
_______________is a selective estrogen receptor modulator indicated to treat osteoporosis in women with vasomotor symptoms. A. Alendronate B. Raloxifene C. Teriparatide D. Denosumab E. Zolendronic Acid
Raloxifene
A 47-year-old postmenopausal woman comes to her family physician due to pain, swelling, and redness in her distal right forearm that began a few days earlier. The pain began while the patient was carrying groceries home from the store. An X-ray indicates a fracture in the patient's distal, right radius, and lab results reveal elevated serum calcium and parathyroid hormone levels. What is the best next step in the management of this patient? A. Daily furosemide treatment B. Estrogen replacement therapy C. Long-term bisphosphonate therapy D. Referral to surgeon EThyroid hormone replacement therapy
Referral to surgeon This patient has hyperparathyroidism as evidenced by the elevated calcium and intact PTH levels. Patients with symptomatic hyperparathyroidism are generally recommended to have a parathyroidectomy, unless they are a poor candidate for surgery in general. This patient's elevated calcium and intact parathyroid hormone levels are consistent with primary hyperparathyroidism, an overactivity of the parathyroid glands resulting in increased PTH secretion and elevated blood calcium levels. Surgery, or parathyroidectomy, is the most common treatment for primary hyperparathyroidism, with cure rates of 95-98% and an estimated complication rate of 1-3%. During the procedure, the surgeon typically removes only those glands that are enlarged or have a tumor (adenoma). If all four glands are affected, a portion of one gland may be left to provide some functioning parathyroid tissue.
(Primary / Secondary) hyperparathyroidism is caused by chronic hypocalcemia which cause the parathyroid gland to makes excess parathyroid hormone.
Secondary
A 67-year-old man comes to the clinic because of progressive pain in his limbs for the past several months. His medical history includes longstanding diabetes mellitus and chronic kidney disease. Three months prior, he fractured two fingers by falling out of his office chair onto a carpeted floor. His current medications include glipizide and atorvastatin. His temperature is 37.0°C (98.6°F), pulse is 88/min, respirations are 12/min, and blood pressure is 172/96 mm Hg. Physical examination shows thin, frail limbs with tenderness to palpation at sites of reported bilateral bone pain. Laboratory serum studies show a parathyroid hormone level of 220 pg/mL and a calcium of 8.4mg/dL. ECG shows a normal sinus rhythm with left ventricular hypertrophy. An ankle x-ray is found to incidentally show vascular calcification. Which of the following is the most likely diagnosis? A. Ostoporosis B. Hypoparathyroidism C. Primary hyperparathyroidism D. Secondary hyperparathyroidism E. Padgett's Disease
Secondary hyperparathyroidism Secondary hyperparathyroidism often occurs in chronic kidney disease and is characterized by an excessive secretion of parathyroid hormone (PTH) from the parathyroid glands due to insufficient levels of ionized calcium in the blood. This leads to excessive breakdown of bone that may increase fracture risk and cardiovascular disease progression.
Which of the following osteoporosis medications is a PTH analog that stimulates osteoblastic activity and is given once daily via subcutaneous injection? A. Alendronate B. Raloxifene C. Teriparatide D. Denosumab E. Zolendronic Acid
Teriparatide
______________ is a recombinant parathyroid hormone used to treat advanced osteoporosis. A. Alendronate B. Raloxifene C. Teriparatide D. Denosumab E. Zolendronic Acid
Teriparatide
A 85-year-old man comes to the emergency department because of back pain for 2 hours. He states that he fell down the stairs at his rest home and is worried that he has broken something. An X-ray is obtained, and in addition to compression fractures, another diagnosis is made. It is decided to start him on Denosumab for this condition. What is the pathophysiologic basis for beginning this medication? A. Increase calcium absorption B. To activate RANK dependent osteoblasts C. To activate RANK dependent osteoclasts D. To inhibit RANK dependent osteoblast apoptosis E. To inhibit RANK dependent osteoclast maturation and activation
To inhibit RANK dependent osteoclast maturation and activation Osteoporosis is thought to be an imbalance of osteoblast and osteoclast activity in bone remodeling. Denosumab is a monoclonal antibody that inhibits RANKL expressed by osteoblasts and therefore prevents the RANK dependent activation of osteoclasts.
A 72-year-old woman comes to you complaining of severe back pain. She reports that she slipped and fell in her shower at home. She also had a wrist fracture two years ago and an ankle fracture last year. The patient reports that she has been taking an over-the-counter vitamin D supplement. She has not had any diffuse bone pain. Figure A shows a radiograph of her spine. Which of the following is the most likely underlying abnormality? A. Superiosteal bone resorption B. Vitamin D deficiencyve unmineralized osteoid C. Excessive unmineralized osteoid D. Trabecular thinning E. Hypocalcemia
Trabecular thinning This patient has osteoporosis, which is an age-related decrease in bone mass in which bony trabeculae become thinner.
________________is a neurological physical exam sign of hypoparathyroidism that presents as carpal spasm following occlusion of the brachial artery by a blood pressure cuff.
Trousseau sign
_____________ compression fractures are a common finding in osteoporosis.
Vertebral
Parathyroid hormone stimulates synthesis of 1,25 OH _____________in the kidney, which increases gastrointestinal absorption of calcium. A. Vitamin A B. Vitamin D C. Vitamin E D. Vitamin K
Vitamin D
Which of the following osteoporosis medications has the possible side-effect of osteonecrosis of the jaw? (2) A. Alendronate B. Raloxifene C. Teriparatide D. Denosumab E. Zolendronic Acid
Zolendronic Acid; Denosumab *Possible Alendronate? also a bisophosphonate
Primary hyperparathyroidism is usually due to parathyroid ____________or hyperplasia.
adenoma
In hypoparathyroidism if there is a disturbance in the serum ____________level, the measured serum calcium should be corrected.
albumin
In the presence of a contraindication to surgery, (calcimimitics/bisphosphonates) are better used to manage low bone density.
bisphosphonates
The medication class __________________are first line therapy for prevention & treatment of osteoporosis.
bisphosphonates
Dual-energy X-ray absorptiometry tests for ___________ and is used to make a definitive diagnosis of osteoporosis.
bone density
Possible side-effects of bisphosphonate drugs include GI upset, esophagitis, gastric ulcers, atypical ________________fracture, hypercalcemia, and increased risk of esophageal cancer.
chalk-stick fracture
Secondary hyperparathyroidism most often happens in the context of ________________ which causes hypovitaminosis D and hyperphosphatemia leading to decreased Ca2+
chronic renal disease,
Calcium levels (decrease/increase) in hypoparathyroidism.
decrease
Serum phosphate levels (increase/decrease) in primary hyperparathyroidism.
decrease
Secondary hyperparathyroidism is secondary to parathyroid hyperplasia due to (decreased/increased) Ca2+ absorption and/or increased PO43−.
decreased
When plasma calcium concentrations are (increased/decreased) , parathyroid hormone is stimulated to return them to normal levels.
decreased
Parathyroid hormone increases blood calcium and (increases/decreases) phosphate level.
decreases
Parathyroid hormone acts to increase renal reabsorption of calcium in the ______________________.
distal convoluted tubule
Parathyroid hormone levels (increase/decrease/do not change) in Paget disease of bone.
do not change
Serum calcium levels (increase/decrease/do not change) in Paget disease of bone.
do not change
Serum phosphate levels (increase/decrease/do not change) in Paget disease of bone.
do not change
Secondary hyperparathyroidism in chronic renal disease will have low calcium, (decreased / elevated) phosphate, and low vitamin D.
elevated
Possible side-effects of bisphosphonate drugs include GI upset, esophagitis, gastric ulcers, atypical chalk-stick fracture, hypercalcemia, and increased risk of _____________ cancer.
esophageal
Patients with a(n) ____________ hormone deficiency are at increased risk of osteoporosis and bone fracture.
estrogen
Postmenopausal (type I) osteoporosis is a type of osteoporosis involving increased bone resorption due to decreased ___________ levels.
estrogen
Hypoparathyroidism can present with (hypo/hyper) active deep tendon reflexes.
hyper
Nephrolithiasis can occur in (hyper/hypo) -parathyroidism.
hyper
Primary hyperparathyroidism is usually due to parathyroid adenoma or ___________.
hyperplasia
(Hyper/Hypo) magnesemia in hypoparathyroidism can result in hypocalcemia with normal parathyroid level.
hypo
Hypoparathyroidism can present with cardiac arrhythmias, due to ____________________.
hypocalcemia
Alkaline phosphatase levels (decrease/increase) in Paget disease of bone.
increase
An isolated (increase / decrease) in serum alkaline phosphatase is commonly indicative of Paget disease of bone.
increase
Paget disease of bone, also known as osteitis deformans, is a common, localized bone disorder that involves an (increase / decrease) in both osteoblastic and osteoclastic activity.
increase
Serum alkaline phosphatase levels (increase/decrease) in primary hyperparathyroidism as it represents bone turnover.
increase
Serum phosphate levels (increase/decrease) increase in secondary hyperparathyroidism.
increase *decrease in primary hyperparathyroidism
Parathyroid hormone (increases / decreases) osteoclast activity in the bone
increases
The method of action of the bisphosphonate class of drugs for osteoporosis is osteoclast (stimulation / inhibition)
inhibition
Parathyroid hormone (stimulates / inhibits) renal net reabsorption of phosphorus and bicarbonate.
inhibits
Patients with hyperparathyroidism commonly present with flank pain secondary to recurrent _____________, a common complication due to increased serum calcium levels.
kidney stones
Secondary hyperparathyroidism in chronic renal disease will have (high / low) calcium, elevated phosphate, and low vitamin D.
low
Secondary hyperparathyroidism in chronic renal disease will have low calcium, elevated phosphate, and (high / low) vitamin D.
low
In the Paget disease of bone, lesions have a mixture of lamellar and woven bone, which gives it a classic __________ pattern.
mosaic
A chronic complication of primary hyperparathyroidism involving the bone is _______________________.
osteitis fibrosa cystica
Parathyroid hormone acts on osteoblasts, which release cytokines that stimulate ____________, which increase bone resorption to release calcium into the blood.
osteoclasts
The concentration of calcium in extracellular fluid is regulated by ______________hormone.
parathyroid
Most common cause of primary hyperparathyroidism is ________________ which is a benign tumor.
parathyroid adenoma
The presence of bone pain in a patient with chronic kidney disease raises suspicion of (primary / secondary) hyperparathyroidism.
secondary
Vitamin D deficiency causes (primary/secondary) secondary hyperparathyroidism.
secondary
Patients with Paget disease of bone may notice increased hat size due to _______________.
skull thickening
When there are low extracellular calcium levels, less calcium binds to the calcium-sensing receptors and this in turn (inhibits/stimulates) the release of parathyroid hormone.
stimulates
The most common cause of hypoparathyroidism is _________________________________________.
surgical removal of the parathyroid glands after thyroidectomy
Symptomatic primary hyperparathyroidism is best managed (medically/surgically) .
surgically
