Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition

Hyperparathyroidism

Case Studies With Answers

A 42-year-old woman complaining of weakness, loss of appetite, and nausea was found to have

hypercalcemia after a blood test taken during a routine physical examination at work. She was

completely asymptomatic, and the results of a physical examination were negative.

Studies Results
Routine laboratory work Normal except for:
Serum calcium, p. 120 12.8 mg/dL (normal: 9.0–10.5 mg/dL)
Phosphorus, p. 351 1.4 mg/dL (normal: 3.0–4.5 mg/dL)
Parathyroid hormone (PTH) test, p. 342 232 pg/mL (normal: 10–65 pg/mL)
X-ray study of skull and hands, pp. 1007, 948 Moderate bone resorption
Bone mineral density scan, p. 943 1.8 (osteopenia)
Bone turnover markers, p. 858 Elevated

Diagnostic Analysis

Although the patient was completely asymptomatic, she had significant hypercalcemia.

Concomitantly elevated PTH levels indicated that her hypercalcemia was the result of primary

hyperparathyroidism. The serum phosphorus reinforced this diagnosis. Radiographic films of the

skull and hands (the most common locations of bone resorption caused by hyperparathyroidism)

showed moderate changes, indicating that the hyperparathyroidism was not an acute process. The

bone mineral density scan was reduced, indicating osteopenia as a result of the

hyperparathyroidism. Elevated bone turnover markers indicate increased bone resorption. The

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Case Studies With Answers 2

patient underwent surgical exploration of the neck, and only three small parathyroid glands were

found. No further surgery was performed.

Neck and chest venous PTH assays were performed postoperatively. PTH levels in all neck veins

were below 10 pg/mL; however, the PTH in the superior vena cava was 308 pg/mL. A

parathyroid scan indicated lit up in the chest. This indicated that a fourth parathyroid gland was

still encased in the chest. The patient underwent surgical exploration of the mediastinum. A large

parathyroid benign adenoma was found and excised. Postoperatively, the patient had no

difficulties, and her calcium level returned to normal.

Critical Thinking Questions

1. What caused the bone resorption in this patient?

PTH regulates serum calcium by increasing calcium reabsorption from the bone, kidney,
and the intestine. PTH enhances bone resorption by osteoclasts, which cause the release
of calcium from the large reservoir contained in the bones.

2. The patient developed hypocalcemia 2 days after the operation. What symptoms

of hypocalcemia should the nurse look for? What are the most likely causes of the

hypocalcemia?

Acute symptoms of calcium deficiency disease include:

 confusion or memory loss
 muscle spasms
 numbness and tingling in the hands, feet, and face
 hallucinations
 muscle cramps
The cause of this patient’s hypocalcemia was the surgical removal of the parathyroid
tissue.

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Case Studies With Answers 3

3. Elevated PTH levels can be considered a normal physiologic response in a patient

with renal failure. Explain the pathophysiology for this process.

In renal failure, the blood phosphorus levels rise. This produces elevated PTH levels.
Also, the diseased kidney cannot activate vitamin D. Without activated vitamin D,
calcium cannot be absorbed from the intestines. When the blood calcium level drops, the
parathyroids respond by producing more PTH. Secondary hyperparathyroidism can
develop.

4. How could a negative surgical neck exploration have been avoided?

A parathyroid scan would have precluded the need for a neck exploration and for
selective venous PTH levels. The scan would have indicated a single focus of increased
nuclear activity in the mediastinum which would more accurately direct parathyroid
surgery.

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