3 Simple Steps for a High Calcium Workup (Plus, Do-Not-Miss Diagnoses)
Listen
Watch
Show notes:
As a new nurse practitioner, I'd get a sinking feeling as I watched new lab results pile up in my inbox every time I'd check my computer between patients.
It's a topic that's somewhat covered in school... but not really. At least, not for most new grads.
Today's video kicks off the Lab Interpretation Series— concise, practical videos to help manage your overflowing lab results pile.
I love high calcium (#nerdalert) because it's one of the simpler labs to work up.
Interpreting High Calcium in Primary Care
In this video, you'll get:
Three easy steps to work up any high calcium
The #1 lab to think of when you see high calcium (bonus points if you can count the number of times I mention it! Ha!)
The hard-to-forget Do-Not-Miss diagnoses
Want to Build More Confidence Interpreting Labs?
If you found this case study helpful, you'll probably enjoy the Lab Interpretation Series.
Inside the series, we take the same practical, case-based approach to interpreting common primary care labs—but go much deeper into the clinical reasoning behind them. Rather than memorizing reference ranges, you'll learn how to recognize patterns, work through differential diagnoses, and apply lab results to real patient care.
The Lab Interpretation Series includes self-paced, ANCC-accredited courses covering CBC, basic metabolic panel, renal labs, liver function tests, thyroid labs, hyperlipidemia, and more.
Learn more about the Lab Interpretation Series →
If you liked this post, also check out:
-
WEBVTT
1
00:00:08.500 --> 00:00:16.560
Hey there, welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator,
2
00:00:16.800 --> 00:00:22.740
and founder of Real World NP, an educational company for nurse practitioners in primary
3
00:00:22.740 --> 00:00:29.100
care. I'm on a mission to equip and guide new nurse practitioners so that they can
4
00:00:29.100 --> 00:00:34.800
feel confident, capable, and take the best care of their patients. If you're looking for clinical
5
00:00:34.800 --> 00:00:40.680
pearls and practice tips without the fluff, you're in the right place. Make sure you subscribe and
6
00:00:40.680 --> 00:00:45.760
leave a review so you won't miss an episode. Plus, you'll find links to all the episodes
7
00:00:45.760 --> 00:00:55.040
with extra goodies over at realworldnp.com slash podcast. Well, hey there, it's Liz Rohr from
8
00:00:55.040 --> 00:00:59.260
Real World NP and you're watching NP Practice Made Simple, the weekly video series to help
9
00:00:59.260 --> 00:01:03.960
save you time, frustration, and help you learn more faster so you can take the best care of your
10
00:01:03.960 --> 00:01:08.180
patients because that's what we all want, right? So today I want to talk to you about high
11
00:01:08.180 --> 00:01:13.360
calcium. I know lab interpretation as a new grad is really confusing, it was for me, and
12
00:01:13.360 --> 00:01:18.420
it's definitely coming up as a topic for a lot of new grads that I've talked to. So I want
13
00:01:18.420 --> 00:01:23.560
to focus on calcium today, high calcium, and really break it down into three simple steps of
14
00:01:23.560 --> 00:01:28.520
investigation and workup. And I'm going to do it by using a case study, a really interesting
15
00:01:28.520 --> 00:01:34.740
case study of my first year. Quick note is that I want to keep it interesting, concise,
16
00:01:35.380 --> 00:01:40.260
and brief because I know that you're really busy. So it's a little bit of a longer video
17
00:01:40.260 --> 00:01:44.940
today, but I've really kept it straight to the point without any fluff. So I hope it's
18
00:01:44.940 --> 00:01:50.360
really helpful. One more quick note is that it is a case study and patients are not
19
00:01:50.360 --> 00:01:54.340
one-dimensional, so that there are many moving parts to this case. I'm really going
20
00:01:54.340 --> 00:01:59.240
to focus on one aspect of it and touch on some of the other management aspects. If there's
21
00:01:59.240 --> 00:02:02.600
a topic in particular that you want to hear more about, definitely leave me a comment
22
00:02:02.600 --> 00:02:07.820
below with the topic or question that you have, and hopefully I've made it as clear
23
00:02:07.820 --> 00:02:12.020
and concise as I can. So without further ado, I'm going to share my screen with
24
00:02:12.020 --> 00:02:16.720
you. All right, so let's get started. So this is the hypercalcemia case study.
25
00:02:16.840 --> 00:02:20.760
We're going to start with Laura. She's 36 years old. She's a new patient to
26
00:02:20.760 --> 00:02:26.080
the clinic. The PHI, personal health information, has been removed. This is not her real name or
27
00:02:26.080 --> 00:02:30.080
her photo. She's a little too happy, unfortunately, based on her clinical
28
00:02:30.080 --> 00:02:37.940
scenario, but no, that is not her. So Laura is a 36-year-old female, new patient to the clinic.
29
00:02:38.680 --> 00:02:41.740
She's there to establish care. She has never been there before. She's coming from a
30
00:02:41.740 --> 00:02:45.520
different clinic. She got her healthcare at a different clinic a couple of years ago.
31
00:02:45.840 --> 00:02:50.020
So she's actually here for an ER follow-up. She had a DVT and it's her first one she's
32
00:02:50.020 --> 00:02:56.320
ever had. She's on a Lovenox bridge until she's therapeutic with her coumadin with a goal of INR
33
00:02:56.320 --> 00:03:01.180
two to three. If you don't know what a Lovenox bridge is or you haven't heard of it before,
34
00:03:01.340 --> 00:03:05.980
it's when patients will get Lovenox and coumadin at the same time until their
35
00:03:05.980 --> 00:03:13.200
INR is within goal and then you stop the Lovenox bridge. So she's a former smoker. She
36
00:03:13.200 --> 00:03:18.140
smoked half a pack a day and she just stopped. She was a little scared by the DVT, I think.
37
00:03:19.080 --> 00:03:23.720
So she's taking Queen Anne's Lace herbal supplement for contraception. So this was actually the first
38
00:03:23.720 --> 00:03:28.100
time I've heard of this and it's not common at all. This is her words, I've never seen any
39
00:03:28.100 --> 00:03:34.760
recommendations about this. I could say a lot of things about this, but let's stay focused for
40
00:03:34.760 --> 00:03:40.020
today. Her past medical history is only significant for a therapeutic abortion a few
41
00:03:40.020 --> 00:03:46.040
years ago. No past surgical history, family history that she knows of. And she's actually
42
00:03:46.040 --> 00:03:49.440
active with one male partner and they're monogamous and she's a working professional.
43
00:03:49.740 --> 00:03:58.180
She works a nine to five job. So the plan, we're going to check her labs. We're going
44
00:03:58.180 --> 00:04:03.780
to check that her INR is therapeutic or not and see if she can stop that Lovenox.
45
00:04:04.320 --> 00:04:09.680
We're going to check a CBC today because we don't have any labs from the hospital and we
46
00:04:09.680 --> 00:04:13.820
want to get a baseline hematocrit and hemoglobin because of the risk of bleeding
47
00:04:13.820 --> 00:04:18.940
for Coumadin. And I'm also going to get a CMP for her because I want to get her baseline
48
00:04:18.940 --> 00:04:25.140
renal and liver function. Most likely it's normal because she's presumably a healthy 36
49
00:04:25.140 --> 00:04:30.380
year old female aside from this DVT, but it's important to check that. And I didn't have any
50
00:04:30.380 --> 00:04:35.640
records from the hospital. So today I'm going to focus on hypercalcima specifically, but I'll
51
00:04:35.640 --> 00:04:39.140
touch on the other components of holistic care at the end because clearly we're not just
52
00:04:39.140 --> 00:04:44.680
focusing on one thing when we're with a patient. So here are her lab results. Surprise,
53
00:04:44.820 --> 00:04:53.740
her calcium is high. You probably saw that coming. So right here is going to be the
54
00:04:55.720 --> 00:05:02.440
BMP, basic metabolic panel. You've got your renal function, calcium is high,
55
00:05:02.640 --> 00:05:07.760
carbon dioxide, creatinine, GFR, renal function is normal. I spliced it over here
56
00:05:07.760 --> 00:05:13.480
with the abbreviated CBC because I wanted it to fit all on one slide, but her potassium is
57
00:05:13.480 --> 00:05:17.840
normal, her sodium is normal. Hematocrit and hemoglobin also baseline normal. So that's a
58
00:05:17.840 --> 00:05:21.000
good thing in case later we check it and it's lower, she could have a risk for bleeding
59
00:05:21.000 --> 00:05:26.980
somewhere because of the Coumadin. So platelets are normal, white blood cells are normal.
60
00:05:27.060 --> 00:05:32.380
Her INR is showing up as abnormal at 2.1 because it's greater than the expected 1.1,
61
00:05:32.380 --> 00:05:36.300
but it's actually normal for her as you saw before. We're looking for a goal of 2 to 3
62
00:05:36.300 --> 00:05:42.420
for her Coumadin. And another note is that her hepatic panel is also normal. I didn't include
63
00:05:42.420 --> 00:05:47.500
it again because I wanted it to fit on one slide, but her albumin, her protein is normal at 3.7
64
00:05:47.500 --> 00:05:53.060
which will be important in a moment. So for hypercalcemia, I want this to be really easy.
65
00:05:53.140 --> 00:05:57.120
I want it to be the three steps that you automatically think of when you see a high
66
00:05:57.120 --> 00:06:04.160
calcium level. So step number one, is it truly high? So calcium is bound to protein
67
00:06:04.160 --> 00:06:08.180
and so you need to correct for the albumin level. So if you have low albumin, you're going to have
68
00:06:08.180 --> 00:06:12.400
a superficially low calcium and vice versa. If you have a high albumin, you're going to have a
69
00:06:12.400 --> 00:06:18.080
higher calcium level which is not necessarily concerning. So you're going to use a calcium
70
00:06:18.080 --> 00:06:23.260
correction calculator. On the Ultimate Resource Guide, there's MD Calc is one of the apps
71
00:06:23.260 --> 00:06:29.820
that you can download or you can just Google it and see what the actual corrected calcium is.
72
00:06:30.380 --> 00:06:37.720
And then the other thing that's expert opinion based on no randomized controlled trials but
73
00:06:37.720 --> 00:06:41.820
expert level of evidence and this is kind of consensus. I see this all the time and I
74
00:06:41.820 --> 00:06:46.580
recommend it as well even though I'm not super fond of that level of evidence. It's not as
75
00:06:46.580 --> 00:06:52.080
strong as a meta-analysis of course. However, it's recommended to repeat the test and make sure
76
00:06:52.080 --> 00:06:57.200
to confirm that this calcium is truly high with another repeated BMP with the albumin
77
00:06:57.200 --> 00:07:03.220
or a complete metabolic panel that includes the albumin or you can repeat it with an ionized
78
00:07:03.220 --> 00:07:06.900
calcium which is a little bit more of a specific test if that's available with your laboratory.
79
00:07:07.060 --> 00:07:12.600
It's not at my current clinic unfortunately but I have used that in the past. So step one,
80
00:07:12.600 --> 00:07:17.840
is it really high? You rechecked it, you confirmed it, it is actually high. Number two
81
00:07:17.840 --> 00:07:21.440
is how high is it and it's actually not quite number two because you have to think about this
82
00:07:21.440 --> 00:07:26.860
at the same time as step number one of the is it truly high because if it's super high and
83
00:07:26.860 --> 00:07:31.860
it's the first lab I'm going to be more concerned about that and I'm probably not going to wait to
84
00:07:31.860 --> 00:07:35.900
recheck it depending on the picture so just stick with me for a second. So how high is it?
85
00:07:36.120 --> 00:07:40.340
So the normal range for calcium and this is dependent on your laboratory but typically is
86
00:07:40.340 --> 00:07:48.000
8.3 to 10.3 so if it's greater than 14 with your calcium correction score or you did an
87
00:07:48.000 --> 00:07:54.100
ionized calcium and it's greater than 10 and the normal for that is up to 4.9 and or they're
88
00:07:54.100 --> 00:07:58.080
symptomatic they need to go to the ER because that's really concerning we should correct that
89
00:07:58.080 --> 00:08:05.000
pretty quickly with some IV fluids and a quick reminder about symptoms of high calcium that's
90
00:08:05.000 --> 00:08:10.480
confusion feeling thirsty all the time peeing all the time you know dehydration lack of
91
00:08:10.480 --> 00:08:16.320
appetite nausea muscle weakness a little bit vague symptoms but something to think about so
92
00:08:16.320 --> 00:08:22.580
is it truly high how high is it is it less than 14 and is it confirmed that it's actually
93
00:08:23.600 --> 00:08:30.740
true high score with the corrected calcium score and then two causes so pretty easy here right so 90
94
00:08:30.740 --> 00:08:34.900
percent of all cases more than 90 percent actually are going to be from two different things
95
00:08:36.679 --> 00:08:42.880
90 percent number one is going to be primary hyperparathyroidism that's just across the
96
00:08:42.880 --> 00:08:46.860
board that's going to be your number one and number two is cancer so that's really concerning
97
00:08:46.860 --> 00:08:52.100
so you should really not dismiss high calcium you know 90 percent hyperparathyroid and
98
00:08:52.100 --> 00:08:58.420
really pretty easy three steps and the top two diagnoses so what's next for her we've determined
99
00:08:58.420 --> 00:09:03.660
it's safe to do an outpatient workup because again the first check it was less than 14 and
100
00:09:03.660 --> 00:09:07.560
she had a normal albumin no symptoms we called her up on the phone the next day when we got
101
00:09:07.560 --> 00:09:11.860
the results and she wasn't having any of those symptoms um regardless i'm going to advise
102
00:09:11.860 --> 00:09:17.020
her of high calcium precautions um and that's staying hydrated avoiding prolonged bed rest which
103
00:09:17.020 --> 00:09:21.320
i'm not really concerned about because she's um ambulatory she works she's a working
104
00:09:21.320 --> 00:09:26.260
professional she's not bed bound she's not wheelchair bound um and avoiding a super high
105
00:09:26.260 --> 00:09:30.260
calcium diet which is a little bit hard to quantify but if you can do a quick ask of like
106
00:09:30.260 --> 00:09:34.940
you know what are you chugging gallons of milk per day or other high calcium foods um
107
00:09:34.940 --> 00:09:40.480
that can hopefully be helpful so a quick med check this is a quick win in terms of
108
00:09:40.940 --> 00:09:45.860
for high calcium does she take any thiazides or lithium which we know in this case she
109
00:09:45.860 --> 00:09:50.120
doesn't we've done a med rec when she first arrived to the clinic but hydrochlorothiazide
110
00:09:50.120 --> 00:09:55.600
tons of people take and um chlorothaladone as well and lithium depending on your patient
111
00:09:55.600 --> 00:09:59.560
population i used to see a ton of lithium so if you see lithium that's definitely something
112
00:09:59.560 --> 00:10:03.960
to think about so we're going to start her work up because it's safe to do outpatient
113
00:10:03.960 --> 00:10:07.860
so hyperparathyroid is going to be the very first one because it's the most likely cause
114
00:10:07.860 --> 00:10:14.700
so you're going to start by ordering an intact pth the cancer workup cause number two most
115
00:10:14.700 --> 00:10:18.380
common cause number two you're going to start that after you roll out the hyperparathyroid
116
00:10:18.380 --> 00:10:24.300
because it's just less common and the labs are a little bit more involved um most of the time
117
00:10:24.300 --> 00:10:27.280
in terms of reassuring you that you're not like staying awake at night thinking this
118
00:10:27.280 --> 00:10:30.980
person has cancer and that you're missing it most of the time calcium is going to be on
119
00:10:30.980 --> 00:10:35.860
the higher side like a 12 or 13 and it's also going to be an acute increase and it's not
120
00:10:35.860 --> 00:10:41.480
going to be chronically high and a note about acuity if someone is acutely has acutely high
121
00:10:41.480 --> 00:10:45.680
calcium they're more likely to be symptomatic than someone who has chronically high calcium
122
00:10:46.320 --> 00:10:50.760
in the case of you know chronic hyperparathyroidism that hasn't been detected in a while
123
00:10:50.760 --> 00:10:56.760
so don't worry about her it's okay so other causes i do not want to overwhelm you by
124
00:10:56.760 --> 00:11:00.500
listing these but it's important to know because it's relevant to the workup
125
00:11:01.020 --> 00:11:05.300
so kind of if you can just start by keeping in your mind the cancer and hyperparathyroidism
126
00:11:05.300 --> 00:11:08.780
here are some other causes and it's going to make sense in a second when i show you the
127
00:11:08.780 --> 00:11:14.700
algorithm so granulomatous diseases lymphoma and tuberculosis not very common but they can
128
00:11:15.660 --> 00:11:20.380
vitamin d toxicity someone's taking a ton of vitamin d supplement that's really important
129
00:11:20.380 --> 00:11:24.680
that you do that supplement med rec when somebody comes in if they're taking over
130
00:11:24.680 --> 00:11:28.800
the counter things you're kind of getting that out of the history multiply multiple
131
00:11:28.800 --> 00:11:33.240
myeloma in my mind i connect it in the i lump it in the cancer category it's a
132
00:11:33.240 --> 00:11:38.340
neoplastic process and it's a little bit complicated but kind of a topic for another
133
00:11:38.340 --> 00:11:42.840
day but um keeping in your mind that it's a less common cause but it'll be relevant
134
00:11:42.840 --> 00:11:47.660
in a second i'll show you and then hyper hyperthyroidism if you have hyperactive
135
00:11:47.660 --> 00:11:52.040
thyroid you can get high calcium medications again thiazides and lithium are the most
136
00:11:52.040 --> 00:11:55.820
common causes there's a couple of other ones that are pretty rare so if you have a patient
137
00:11:55.820 --> 00:12:00.720
who has rare medications like forteo is one of them which is that injectable osteoporosis
138
00:12:00.720 --> 00:12:06.480
medication other one i actually don't i've never seen it before so weird meds double
139
00:12:06.480 --> 00:12:11.820
check the side effects uncommon meds i should say not necessarily weird but um and other
140
00:12:12.620 --> 00:12:15.960
hereditary abnormalities but this is outside the scope of primary care so if you've done
141
00:12:15.960 --> 00:12:20.080
your workup and you're getting to this point they definitely need like in my mind i almost
142
00:12:20.080 --> 00:12:24.280
just like that's fine like i don't even need to remember the names of those things because
143
00:12:24.280 --> 00:12:27.860
they're going to be going to an endocrinologist and i've done my job as a primary care
144
00:12:27.860 --> 00:12:34.300
provider and doing the initial workup and labs for safety so here's the algorithm i
145
00:12:34.300 --> 00:12:37.980
really don't want to overwhelm me but i'm such a visual person that i find this really
146
00:12:37.980 --> 00:12:42.860
helpful and if you're listening to this instead of watching it hopefully i can go slow enough
147
00:12:42.860 --> 00:12:48.700
that it makes sense so number one just reiterating again we're going to confirm that it's hyper
148
00:12:50.140 --> 00:12:54.600
calcemia step number two is we're going to check the intact pth and if it's high
149
00:12:54.600 --> 00:12:59.320
that's one way you're going to you know evaluate that further or if it's low then
150
00:12:59.320 --> 00:13:02.340
you're and i have a star asterisk there because on the next slide i'm going to
151
00:13:02.340 --> 00:13:06.600
get into that in one second just a little note about pth if it's low and it doesn't
152
00:13:06.600 --> 00:13:11.160
seem like a type of parathyroid you're going to move on to that cancer and other cause of workup
153
00:13:12.080 --> 00:13:17.440
so this is this is based on the up-to-date algorithm which is congruent with the other
154
00:13:17.440 --> 00:13:24.660
resources that i found so pth rp is pth related peptide or protein which is related to kind of
155
00:13:24.660 --> 00:13:30.140
a neoplastic process vitamin d 25 is the active form of vitamin d and vitamin d 125
156
00:13:30.140 --> 00:13:34.900
is the inactive form which is relevant in just a sec you can hold on stick with me
157
00:13:34.900 --> 00:13:40.860
and then um if you the next step after that is to check the s pep in upep and free
158
00:13:41.500 --> 00:13:46.220
light chain assay which is uh that kind of bottom step where you're moving towards the
159
00:13:46.220 --> 00:13:51.360
multiple myeloma so so that's kind of a lot of information but just stick with me for one
160
00:13:51.360 --> 00:13:56.020
second so we're going to move to the workup for this particular patient laura her calcium
161
00:13:56.020 --> 00:14:02.180
is 11.5 so number one again in order intact pth if you only take one thing away from this
162
00:14:02.180 --> 00:14:07.920
just don't ignore high calcium and check a pth step number one the really important note here
163
00:14:07.920 --> 00:14:15.020
that i want to make is that the normal range is 10 to 60 and i'm sorry i i left off the the
164
00:14:15.020 --> 00:14:19.720
markers um the units of measurement here but up to the algorithm which also agrees with other
165
00:14:19.720 --> 00:14:26.100
sources is that high mid to upper normal range is also considered to be abnormal so 35 to 65
166
00:14:26.100 --> 00:14:31.360
even though technically it's only elevated above 60 so don't ignore that so when you're
167
00:14:31.360 --> 00:14:35.680
going through your labs and you're looking through the pth like don't just scroll over
168
00:14:35.680 --> 00:14:40.060
it because it's not a bright red color or a bolded abnormal range it's still important
169
00:14:40.060 --> 00:14:44.020
to paint the actual number and you can look up that reference page i look it up every
170
00:14:44.020 --> 00:14:50.380
single time so vitamin d so for this patient i ordered an intact pth the vitamin d and the
171
00:14:50.380 --> 00:14:55.600
tsh and i know i just said that the most common causes are the are the pth and then
172
00:14:55.600 --> 00:15:00.660
cancer so why am i ordering things that are farther down the line and my kind of a real
173
00:15:00.660 --> 00:15:05.960
point here is that i want to as a primary care provider i'm going to order the tests
174
00:15:05.960 --> 00:15:12.620
that i can do something about um uh in the clinic and so but vitamin d and tsh
175
00:15:13.460 --> 00:15:17.700
also like just quick wins like let's just make sure it's not that because the other
176
00:15:17.700 --> 00:15:22.980
labs that are in are kind of involved um these three uh the pth rp i did not order
177
00:15:22.980 --> 00:15:27.600
that at the time and i did not feel comfortable ordering that again the 125 oh and the aspect
178
00:15:28.080 --> 00:15:33.340
free light chain assay i think four years in and having an internal medicine physician that i
179
00:15:33.340 --> 00:15:37.300
work with i'd feel much more comfortable ordering those but for this patient in my first year of
180
00:15:37.300 --> 00:15:43.720
practice i ordered those first three um to start and the other note about that is that
181
00:15:43.720 --> 00:15:48.480
because she's a working professional um we can go back and go back real quick um so if
182
00:15:48.480 --> 00:15:53.060
you're looking at this mount management algorithm it says step one there you check the calcium
183
00:15:53.060 --> 00:15:56.660
step two you check this lab step three you check this up step four you check like that's
184
00:15:56.660 --> 00:16:01.920
a lot of times to come back and get some labs drawn so for this patient i just kind of lumped
185
00:16:01.920 --> 00:16:05.160
them all together because i don't want to number one i don't want to lose her to follow up because
186
00:16:05.160 --> 00:16:10.840
i work in a federally qualified health center um and a lot of my patients have kind of
187
00:16:11.640 --> 00:16:15.980
tumultuous uh lives and it can be very hard for them to get to the clinic and i also don't
188
00:16:15.980 --> 00:16:19.120
just don't want to lose her to follow up and i want to make you know patient-centered
189
00:16:19.120 --> 00:16:22.620
care i holistic care i want to make sure that you know she's not getting stuck three
190
00:16:22.620 --> 00:16:29.200
um and that she's able to get the good care that she needs so yeah so those are my real
191
00:16:29.200 --> 00:16:33.680
world notes about that is that personally i started with the intact pth and vitamin d and
192
00:16:33.680 --> 00:16:40.560
a tsh now as a more established primary care provider with like supportive supervision i feel
193
00:16:40.560 --> 00:16:43.940
like i could also order that but i probably wouldn't order that right away i'd probably
194
00:16:43.940 --> 00:16:48.500
batch it into two different blood draws just to kind of conserve um resources and based on
195
00:16:48.500 --> 00:16:54.100
so so results here are her results so um i rechecked the ionized calcium at the same time
196
00:16:54.100 --> 00:16:58.520
instead of doing a recheck and then coming back again ionized calcium at that time
197
00:16:59.060 --> 00:17:05.579
uh was still elevated so it truly was a high calcium her intact pth is 59 her vitamin d is
198
00:17:05.579 --> 00:17:11.040
is 40 which is normal tsh is normal um but yeah note here high normal so she still needs
199
00:17:11.040 --> 00:17:17.630
a workup even though it's technically within the normal range so let's go back to laura
200
00:17:17.630 --> 00:17:22.910
she is looking happy still but uh she was not at the time she was a little bit worried and
201
00:17:22.910 --> 00:17:28.190
concerned and i was too but you know step one um i referred her to endocrine because
202
00:17:29.530 --> 00:17:34.570
at that point the testing that she needed for a hyperparathyroid workup like i didn't even have
203
00:17:34.570 --> 00:17:39.250
access to the type of labs that she would need to do and so that's an easy place to
204
00:17:39.250 --> 00:17:44.270
draw a line in the pcp in terms of specialty versus in-house and i'm certainly not going to
205
00:17:44.270 --> 00:17:48.130
the treatment for it and hyperparathyroid is its own topic so i'm not really going to get into
206
00:17:48.130 --> 00:17:53.330
that right now but refer to endocrine and in terms of her other holistic care because she
207
00:17:53.330 --> 00:17:57.610
came there originally for the dbt i'm going to stop her lovinox because her inr was therapeutic
208
00:17:57.610 --> 00:18:01.750
i'm still going to manage her kumadin in-house and you might not necessarily do that at your
209
00:18:01.750 --> 00:18:06.370
clinic but i've got a great algorithm for management um if you are interested in looking
210
00:18:06.370 --> 00:18:12.810
at that um some people go to kumadin clinics but it really depends so smoking cessation
211
00:18:12.810 --> 00:18:17.250
reinforcing she's already stopped but we're going to continue you know you know that's probably
212
00:18:17.250 --> 00:18:21.590
related to your dbt uh we talked about contraception and that i didn't really
213
00:18:21.590 --> 00:18:27.370
recommend her to do that um not high levels of evidence but anyway longer discussion for
214
00:18:27.370 --> 00:18:32.730
another time uh heme referral so i was pretty uncomfortable at the time and and i'm getting
215
00:18:32.730 --> 00:18:38.770
more comfortable in terms of dbt and and blood clot management there's a topic with
216
00:18:38.770 --> 00:18:44.370
blood clots of whether this is a provoked or unprovoked dbt and that determines how long you
217
00:18:44.370 --> 00:18:48.190
need to take kumadin for and i didn't feel comfortable with it at the time so i had her
218
00:18:48.190 --> 00:18:53.090
see hematology i probably would feel a lot more comfortable with that now so at the time i had
219
00:18:53.090 --> 00:18:56.950
her follow up with me in a month um and then three months after that just to kind of make
220
00:18:56.950 --> 00:19:02.210
sure that she was still feeling okay um things were going well uh and she was able to get
221
00:19:02.210 --> 00:19:07.610
connected to the specialist that she needed to go to the endocrine so that's it uh leave
222
00:19:07.610 --> 00:19:11.390
a comment below i'd love to hear from you what is the number one takeaway that you've had from
223
00:19:11.390 --> 00:19:19.010
this presentation hopefully rechecking your calcium and checking your pth but uh but yeah
224
00:19:19.010 --> 00:19:23.590
definitely leave me a comment below did you like this video if so if you're on youtube
225
00:19:23.590 --> 00:19:27.830
like it subscribe and be sure to share with your np friends so we can reach as many new
226
00:19:27.830 --> 00:19:31.670
grads as possible to help make this first year a little bit easier and don't forget
227
00:19:31.670 --> 00:19:36.930
to sign up for the email list at real world real world np.com you'll get these videos
228
00:19:36.930 --> 00:19:40.830
straight to your inbox every week with little notes from me and some bonus content that i
229
00:19:40.830 --> 00:19:45.150
just don't share anywhere else hang in there thank you so much for watching and i'll see you
230
00:19:45.150 --> 00:19:53.170
next time that's our episode for today thank you so much for listening make sure you
231
00:19:53.170 --> 00:19:58.850
subscribe leave a review and tell all your np friends so together we can help as many
232
00:19:58.850 --> 00:20:03.790
nurse practitioners as possible give the best care to their patients if you haven't gotten
233
00:20:03.790 --> 00:20:09.630
your copy of the ultimate resource guide for the new np head over to real world np.com
234
00:20:09.630 --> 00:20:14.850
slash guide you'll get these episodes sent straight to your inbox every week with notes
235
00:20:14.850 --> 00:20:19.830
from me patient stories and extra bonuses i really just don't share anywhere else
236
00:20:19.830 --> 00:20:23.170
thank you so much again for listening take care and talk soon
© 2025 Real World NP. For educational and informational purposes only, see realworldnp.com/disclaimer for full details.
