Drug History:

Penicillin 1,200,000 monthly (10 year)

Post surgery Caco3 tab Calcitriol tab Calcitonin amp

III I II

TDS TDS qd

10/24
Test WBC Hb MCV Plt BS Cr Na K Result 4200 9.8 84 119000 94 0.6 141 4.2

Ca
P Mg AST ALT ALP

5.2
3 1.7 40.2 41.1 3378

Check Ca- P QID Mg daily ECG Daily

Primary Hyperpathyroidism
Single adenomas account for up to 89 percent of cases of primary hyperparathyroidism Patients are usually asymptomatic and have mild hypercalcemia, occasionally, patients are normocalcemic, and elevated parathyroid hormone levels are detected

Symptoms and signs of excess parathyroid hormone secretion

Symptoms and signs of hypercalcemia Bone disease Nephrolithiasis Hypophosphatemia Increased production of calcitriol Proximal renal tubular acidosis Hypomagnesemia Hyperuricemia and gout Anemia

Clinical manifestations of hypercalcemia

Renal Polyuria Polydipsia Nephrolithiasis Nephrocalcinosis Distal renal tubular acidosis Nephrogenic diabetes insipidus Acute and chronic renal insufficiency Gastrointestinal Anorexia, nausea, vomiting Bowel hypomotility and constipation Pancreatitis Peptic ulcer disease Musculoskeletal Muscle weakness Bone pain Osteopenia/osteoporosis Neurologic Decreased concentration Confusion Fatigue Stupor, coma

Cardiovascular Shortening of the QT interval Bradycardia Hypertension

Bones Stones Abdominal moans Psychic groans

Management of primary hyperparathyroidism

Patients with symptomatic primary hyperparathyroidism should have parathyroid surgery Cost of follow-up visits and tests may ultimately exceed the costs of surgery

Comparison of new and old guidelines for parathyroid surgery in asymptomatic PHPT Measurement
Serum calcium (>upper limit of normal) 24-h urine for calcium Creatinine clearance (calculated) BMD

1990
1-1.6 mg/dl (0.25-0.4 mmol/liter) >400 mg/d (>10 mmol/d) Reduced by 30 percent Z-score <-2.0 in forearm

2002
1.0 mg/dl (0.25 mmol/liter)
>400 mg/d (>10 mmol/d) Reduced by 30 percent T-score <-2.5 at any site

2008
1.0 mg/dl (0.25 mmol/liter) Not indicated Reduced to <60 ml/min T-score <-2.5 at any site and/or previous fracture fragility

Age (yr)

<50

<50

<50

Hungry bone syndrome following parathyroidectomy

Hypocalcemia is a common problem after parathyroidectomy

due to functional or relative hypoparathyroidism

Severe and prolonged postoperative hypocalcemia despite

normal or even elevated levels of parathyroid hormone (PTH). called the hungry bone syndrome

Hypocalcemia Hypophosphatemia Hypomagnesemia Hyperkalemia

Criteria for the diagnosis of the hungry bone syndrome

On the third postoperative day (13%) Calcium concentration below 8.5 mg/dL phosphate concentration below 3.0 mg/dL

Hungry bone syndrome following parathyroidectomy in patients with secondary hyperparathyroidism due to endstage renal disease (20%)

Risk factors
Volume of the resected adenoma Preoperative blood urea nitrogen concentration Preoperative alkaline phosphatase concentration Older age

Hypocalcemia after parathyroidectomy

PREVENTION
Oral calcium 2 to 3 grams per day two days prior to

surgery
Intravenous calcitriol (2 mcg at the end of each

hemodialysis treatment) begun three to five days prior to surgery and continued postoperatively
Preoperative administration of bisphosphonates

TREATMENT
Oral calcium supplementation 2 to 4 g of elemental

calcium Intravenous calcium - frank tetany, latent tetany (Chvostek's or Trousseau's sign), or a plasma calcium concentration below 7.5mg/dL Intravenous calcium (90 to 180 mg of calcium gluconate in 50 mL of 5 percent dextrose) infused over 10 to 20 minutes. Then solution containing 1 mg/mL of elemental calcium gluconate infused by rate of 50 mL/h (typical requirement 0.5 to 1.5 mg/kg/hour)

 The calcium should be diluted in dextrose and water or

saline, because concentrated calcium solutions are irritating to veins.

The intravenous solution should not contain bicarbonate

or phosphate, which can form insoluble calcium salts. If these anions are needed, another intravenous line (in another limb) should be used.

 Calcitriol in doses up to 4 mcg/day Thiazide diuretic 25 to 100 mg daily Hypomagnesemia

Hypocalcemic-hypomagnesemic patient with tetany should receive 50 meq of intravenous magnesium given slowly over 8 to 24 hours, in normomagnesemic patient with hypocalcemia, it has been suggested to repeat this dose daily for three to five days Hypophosphatemia Hyperkalemia

Recommendations
Caco3

tab Calcitriol tab Calcitonin amp Mgso4

III I II

TDS I TDS or QID TDS Increase doses qd DC 50 meq /24hr

9/25
Test Ca
P Mg

1 5.2
3.8 1.17

2 6.8
3.7

3 6.8
3.7

4 7.4
3.5

Caco3 tab I TDS Calcitriol tab I TDS Ca Gluconate 10 vial in 1 liter D/W over 24 hr Oxazepam tab I Hs

QID

9/27
Test Ca
P Mg

1 7.4
3.5 1.4

2 7
4.7

3 6.5
3.5

4 7
4

Caco3 tab I TDS Calcitriol tab I QID Ca Gluconate 10 vial in 1 liter D/W over 24 hr Oxazepam tab I Hs Hydrochlorthiazide tab I TDS

II

QID

9/29
Test Ca
P

1 6.8
3.9

2 7.1
3.5

3 6.5
4

4 6.4
3.5

Caco3 tab I TDS Calcitriol tab II QID Ca Gluconate 10 vial in 1 liter D/W over 24 hr Oxazepam tab I Hs Hydrochlorthiazide tab TDS

III

QID

10/1
Test Ca
P

1 7.5
4.2

2 6.2
3.9

3 7.5
3.7

4 7.8
4.3

Caco3 tab I TDS Calcitriol tab III QID Ca Gluconate 10 vial in 1 liter D/W over 24 hr Oxazepam tab I Hs Hydrochlorthiazide tab TDS

IV

QID

10/2 10/7
Test Ca
P

10/2 7.5
4.2

10/3 7.5
3.9

10/4 8
4.3

10/5 8.1
4

10/6 8.3
4.1 II V

10/7 8.3
4.3 TDS QID

Caco3 tab I TDS Calcitriol tab IV QID Ca Gluconate 10 vial in 1 liter D/W over 24 hr Oxazepam tab I Hs Hydrochlorthiazide tab I TDS

TDS