Good thoughts all around. I will preface this with saying that this patient in uninsured, so my approach is not going to be exactly textbook since I'm trying to avoid ordering any tests that I don't absolutely have to. I think this has particular value as it forces me to really think before I reflexively order anything.
First, recheck the calcium. The week before I had a patient with an iron of 270. I got everything ready for a hemachromatosis work up then decided to repeat iron levels. Stone cold normal. Always recheck an abnormal if its not something you're expecting to find.
In this case, a repeat was 11.8.
Ionized calcium is a excellent idea, but if you have a normal albumin, normal total protein, normal bicarb, and the patient isn't hyperventilating in front of you, then you've accounted for almost everything that can cause the serum level to be inaccurate.
PTH-related protein is also a good idea as its always wise to distinguish between hyperparathyroid and cancer, however in this case I have an asymptomatic patient with no pain, weight loss, or really any symptoms at all so I'm not too worried about cancer. Plus, even at my prices its expensive - I offered but didn't argue very hard when the patient declined.
PTH ended up being 215, so primary hyperparathyroid is likely what's going on here.
Normally surgery is indicated for these patients, but for self-pay that's not really an option. What would you do from here to manage medically?
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