3 Simple Steps for a High Calcium Workup (Plus, Do-Not-Miss Diagnoses)
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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
Lab Interpretation Crash Course
If you liked this episode, it's a sneak preview of how we cover labs inside our comprehensive Lab Interpretation Crash Course. It covers CBC, CMP, Urinalysis, Dipstick & Microscopy, TSH, Lipids & top Endocrine labs in primary care, and comes with lifetime access and continuing education credits! Check it out here.
If you liked this post, also check out:
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Hey there, welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator,
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and founder of Real World NP, an educational company for nurse practitioners in primary
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care. I'm on a mission to equip and guide new nurse practitioners so that they can
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feel confident, capable, and take the best care of their patients. If you're looking for clinical
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pearls and practice tips without the fluff, you're in the right place. Make sure you subscribe and
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leave a review so you won't miss an episode. Plus, you'll find links to all the episodes
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with extra goodies over at realworldnp.com slash podcast. Well, hey there, it's Liz Rohr from
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Real World NP and you're watching NP Practice Made Simple, the weekly video series to help
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save you time, frustration, and help you learn more faster so you can take the best care of your
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patients because that's what we all want, right? So today I want to talk to you about high
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calcium. I know lab interpretation as a new grad is really confusing, it was for me, and
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it's definitely coming up as a topic for a lot of new grads that I've talked to. So I want
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to focus on calcium today, high calcium, and really break it down into three simple steps of
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investigation and workup. And I'm going to do it by using a case study, a really interesting
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case study of my first year. Quick note is that I want to keep it interesting, concise,
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and brief because I know that you're really busy. So it's a little bit of a longer video
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today, but I've really kept it straight to the point without any fluff. So I hope it's
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really helpful. One more quick note is that it is a case study and patients are not
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one-dimensional, so that there are many moving parts to this case. I'm really going
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to focus on one aspect of it and touch on some of the other management aspects. If there's
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a topic in particular that you want to hear more about, definitely leave me a comment
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below with the topic or question that you have, and hopefully I've made it as clear
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and concise as I can. So without further ado, I'm going to share my screen with
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you. All right, so let's get started. So this is the hypercalcemia case study.
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We're going to start with Laura. She's 36 years old. She's a new patient to
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the clinic. The PHI, personal health information, has been removed. This is not her real name or
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her photo. She's a little too happy, unfortunately, based on her clinical
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scenario, but no, that is not her. So Laura is a 36-year-old female, new patient to the clinic.
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She's there to establish care. She has never been there before. She's coming from a
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different clinic. She got her healthcare at a different clinic a couple of years ago.
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So she's actually here for an ER follow-up. She had a DVT and it's her first one she's
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ever had. She's on a Lovenox bridge until she's therapeutic with her coumadin with a goal of INR
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two to three. If you don't know what a Lovenox bridge is or you haven't heard of it before,
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it's when patients will get Lovenox and coumadin at the same time until their
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INR is within goal and then you stop the Lovenox bridge. So she's a former smoker. She
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smoked half a pack a day and she just stopped. She was a little scared by the DVT, I think.
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So she's taking Queen Anne's Lace herbal supplement for contraception. So this was actually the first
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time I've heard of this and it's not common at all. This is her words, I've never seen any
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recommendations about this. I could say a lot of things about this, but let's stay focused for
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today. Her past medical history is only significant for a therapeutic abortion a few
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years ago. No past surgical history, family history that she knows of. And she's actually
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active with one male partner and they're monogamous and she's a working professional.
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She works a nine to five job. So the plan, we're going to check her labs. We're going
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to check that her INR is therapeutic or not and see if she can stop that Lovenox.
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We're going to check a CBC today because we don't have any labs from the hospital and we
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want to get a baseline hematocrit and hemoglobin because of the risk of bleeding
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for Coumadin. And I'm also going to get a CMP for her because I want to get her baseline
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renal and liver function. Most likely it's normal because she's presumably a healthy 36
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year old female aside from this DVT, but it's important to check that. And I didn't have any
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records from the hospital. So today I'm going to focus on hypercalcima specifically, but I'll
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touch on the other components of holistic care at the end because clearly we're not just
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focusing on one thing when we're with a patient. So here are her lab results. Surprise,
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her calcium is high. You probably saw that coming. So right here is going to be the
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BMP, basic metabolic panel. You've got your renal function, calcium is high,
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carbon dioxide, creatinine, GFR, renal function is normal. I spliced it over here
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with the abbreviated CBC because I wanted it to fit all on one slide, but her potassium is
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normal, her sodium is normal. Hematocrit and hemoglobin also baseline normal. So that's a
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good thing in case later we check it and it's lower, she could have a risk for bleeding
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somewhere because of the Coumadin. So platelets are normal, white blood cells are normal.
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Her INR is showing up as abnormal at 2.1 because it's greater than the expected 1.1,
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but it's actually normal for her as you saw before. We're looking for a goal of 2 to 3
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for her Coumadin. And another note is that her hepatic panel is also normal. I didn't include
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it again because I wanted it to fit on one slide, but her albumin, her protein is normal at 3.7
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which will be important in a moment. So for hypercalcemia, I want this to be really easy.
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I want it to be the three steps that you automatically think of when you see a high
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calcium level. So step number one, is it truly high? So calcium is bound to protein
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and so you need to correct for the albumin level. So if you have low albumin, you're going to have
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a superficially low calcium and vice versa. If you have a high albumin, you're going to have a
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higher calcium level which is not necessarily concerning. So you're going to use a calcium
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correction calculator. On the Ultimate Resource Guide, there's MD Calc is one of the apps
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that you can download or you can just Google it and see what the actual corrected calcium is.
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And then the other thing that's expert opinion based on no randomized controlled trials but
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expert level of evidence and this is kind of consensus. I see this all the time and I
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recommend it as well even though I'm not super fond of that level of evidence. It's not as
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strong as a meta-analysis of course. However, it's recommended to repeat the test and make sure
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to confirm that this calcium is truly high with another repeated BMP with the albumin
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or a complete metabolic panel that includes the albumin or you can repeat it with an ionized
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calcium which is a little bit more of a specific test if that's available with your laboratory.
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It's not at my current clinic unfortunately but I have used that in the past. So step one,
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is it really high? You rechecked it, you confirmed it, it is actually high. Number two
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is how high is it and it's actually not quite number two because you have to think about this
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at the same time as step number one of the is it truly high because if it's super high and
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it's the first lab I'm going to be more concerned about that and I'm probably not going to wait to
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recheck it depending on the picture so just stick with me for a second. So how high is it?
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So the normal range for calcium and this is dependent on your laboratory but typically is
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8.3 to 10.3 so if it's greater than 14 with your calcium correction score or you did an
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ionized calcium and it's greater than 10 and the normal for that is up to 4.9 and or they're
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symptomatic they need to go to the ER because that's really concerning we should correct that
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pretty quickly with some IV fluids and a quick reminder about symptoms of high calcium that's
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confusion feeling thirsty all the time peeing all the time you know dehydration lack of
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appetite nausea muscle weakness a little bit vague symptoms but something to think about so
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is it truly high how high is it is it less than 14 and is it confirmed that it's actually
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true high score with the corrected calcium score and then two causes so pretty easy here right so 90
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percent of all cases more than 90 percent actually are going to be from two different things
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90 percent number one is going to be primary hyperparathyroidism that's just across the
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board that's going to be your number one and number two is cancer so that's really concerning
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so you should really not dismiss high calcium you know 90 percent hyperparathyroid and
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really pretty easy three steps and the top two diagnoses so what's next for her we've determined
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it's safe to do an outpatient workup because again the first check it was less than 14 and
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she had a normal albumin no symptoms we called her up on the phone the next day when we got
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the results and she wasn't having any of those symptoms um regardless i'm going to advise
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her of high calcium precautions um and that's staying hydrated avoiding prolonged bed rest which
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i'm not really concerned about because she's um ambulatory she works she's a working
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professional she's not bed bound she's not wheelchair bound um and avoiding a super high
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calcium diet which is a little bit hard to quantify but if you can do a quick ask of like
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you know what are you chugging gallons of milk per day or other high calcium foods um
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that can hopefully be helpful so a quick med check this is a quick win in terms of
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for high calcium does she take any thiazides or lithium which we know in this case she
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doesn't we've done a med rec when she first arrived to the clinic but hydrochlorothiazide
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tons of people take and um chlorothaladone as well and lithium depending on your patient
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population i used to see a ton of lithium so if you see lithium that's definitely something
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to think about so we're going to start her work up because it's safe to do outpatient
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so hyperparathyroid is going to be the very first one because it's the most likely cause
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so you're going to start by ordering an intact pth the cancer workup cause number two most
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common cause number two you're going to start that after you roll out the hyperparathyroid
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because it's just less common and the labs are a little bit more involved um most of the time
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in terms of reassuring you that you're not like staying awake at night thinking this
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person has cancer and that you're missing it most of the time calcium is going to be on
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the higher side like a 12 or 13 and it's also going to be an acute increase and it's not
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going to be chronically high and a note about acuity if someone is acutely has acutely high
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calcium they're more likely to be symptomatic than someone who has chronically high calcium
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in the case of you know chronic hyperparathyroidism that hasn't been detected in a while
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so don't worry about her it's okay so other causes i do not want to overwhelm you by
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listing these but it's important to know because it's relevant to the workup
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so kind of if you can just start by keeping in your mind the cancer and hyperparathyroidism
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here are some other causes and it's going to make sense in a second when i show you the
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algorithm so granulomatous diseases lymphoma and tuberculosis not very common but they can
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vitamin d toxicity someone's taking a ton of vitamin d supplement that's really important
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that you do that supplement med rec when somebody comes in if they're taking over
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the counter things you're kind of getting that out of the history multiply multiple
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myeloma in my mind i connect it in the i lump it in the cancer category it's a
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neoplastic process and it's a little bit complicated but kind of a topic for another
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day but um keeping in your mind that it's a less common cause but it'll be relevant
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in a second i'll show you and then hyper hyperthyroidism if you have hyperactive
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thyroid you can get high calcium medications again thiazides and lithium are the most
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common causes there's a couple of other ones that are pretty rare so if you have a patient
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who has rare medications like forteo is one of them which is that injectable osteoporosis
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medication other one i actually don't i've never seen it before so weird meds double
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check the side effects uncommon meds i should say not necessarily weird but um and other
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hereditary abnormalities but this is outside the scope of primary care so if you've done
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your workup and you're getting to this point they definitely need like in my mind i almost
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just like that's fine like i don't even need to remember the names of those things because
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they're going to be going to an endocrinologist and i've done my job as a primary care
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provider and doing the initial workup and labs for safety so here's the algorithm i
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really don't want to overwhelm me but i'm such a visual person that i find this really
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helpful and if you're listening to this instead of watching it hopefully i can go slow enough
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that it makes sense so number one just reiterating again we're going to confirm that it's hyper
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calcemia step number two is we're going to check the intact pth and if it's high
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that's one way you're going to you know evaluate that further or if it's low then
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you're and i have a star asterisk there because on the next slide i'm going to
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get into that in one second just a little note about pth if it's low and it doesn't
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seem like a type of parathyroid you're going to move on to that cancer and other cause of workup
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so this is this is based on the up-to-date algorithm which is congruent with the other
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resources that i found so pth rp is pth related peptide or protein which is related to kind of
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a neoplastic process vitamin d 25 is the active form of vitamin d and vitamin d 125
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is the inactive form which is relevant in just a sec you can hold on stick with me
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and then um if you the next step after that is to check the s pep in upep and free
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light chain assay which is uh that kind of bottom step where you're moving towards the
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multiple myeloma so so that's kind of a lot of information but just stick with me for one
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second so we're going to move to the workup for this particular patient laura her calcium
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is 11.5 so number one again in order intact pth if you only take one thing away from this
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just don't ignore high calcium and check a pth step number one the really important note here
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that i want to make is that the normal range is 10 to 60 and i'm sorry i i left off the the
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markers um the units of measurement here but up to the algorithm which also agrees with other
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sources is that high mid to upper normal range is also considered to be abnormal so 35 to 65
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even though technically it's only elevated above 60 so don't ignore that so when you're
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going through your labs and you're looking through the pth like don't just scroll over
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it because it's not a bright red color or a bolded abnormal range it's still important
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to paint the actual number and you can look up that reference page i look it up every
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single time so vitamin d so for this patient i ordered an intact pth the vitamin d and the
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tsh and i know i just said that the most common causes are the are the pth and then
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cancer so why am i ordering things that are farther down the line and my kind of a real
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point here is that i want to as a primary care provider i'm going to order the tests
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that i can do something about um uh in the clinic and so but vitamin d and tsh
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also like just quick wins like let's just make sure it's not that because the other
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labs that are in are kind of involved um these three uh the pth rp i did not order
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that at the time and i did not feel comfortable ordering that again the 125 oh and the aspect
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free light chain assay i think four years in and having an internal medicine physician that i
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work with i'd feel much more comfortable ordering those but for this patient in my first year of
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practice i ordered those first three um to start and the other note about that is that
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because she's a working professional um we can go back and go back real quick um so if
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you're looking at this mount management algorithm it says step one there you check the calcium
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step two you check this lab step three you check this up step four you check like that's
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a lot of times to come back and get some labs drawn so for this patient i just kind of lumped
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them all together because i don't want to number one i don't want to lose her to follow up because
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i work in a federally qualified health center um and a lot of my patients have kind of
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tumultuous uh lives and it can be very hard for them to get to the clinic and i also don't
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just don't want to lose her to follow up and i want to make you know patient-centered
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care i holistic care i want to make sure that you know she's not getting stuck three
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um and that she's able to get the good care that she needs so yeah so those are my real
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world notes about that is that personally i started with the intact pth and vitamin d and
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a tsh now as a more established primary care provider with like supportive supervision i feel
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like i could also order that but i probably wouldn't order that right away i'd probably
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batch it into two different blood draws just to kind of conserve um resources and based on
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so so results here are her results so um i rechecked the ionized calcium at the same time
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instead of doing a recheck and then coming back again ionized calcium at that time
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uh was still elevated so it truly was a high calcium her intact pth is 59 her vitamin d is
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is 40 which is normal tsh is normal um but yeah note here high normal so she still needs
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a workup even though it's technically within the normal range so let's go back to laura
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she is looking happy still but uh she was not at the time she was a little bit worried and
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concerned and i was too but you know step one um i referred her to endocrine because
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at that point the testing that she needed for a hyperparathyroid workup like i didn't even have
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access to the type of labs that she would need to do and so that's an easy place to
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draw a line in the pcp in terms of specialty versus in-house and i'm certainly not going to
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the treatment for it and hyperparathyroid is its own topic so i'm not really going to get into
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that right now but refer to endocrine and in terms of her other holistic care because she
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came there originally for the dbt i'm going to stop her lovinox because her inr was therapeutic
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i'm still going to manage her kumadin in-house and you might not necessarily do that at your
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clinic but i've got a great algorithm for management um if you are interested in looking
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at that um some people go to kumadin clinics but it really depends so smoking cessation
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reinforcing she's already stopped but we're going to continue you know you know that's probably
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related to your dbt uh we talked about contraception and that i didn't really
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recommend her to do that um not high levels of evidence but anyway longer discussion for
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another time uh heme referral so i was pretty uncomfortable at the time and and i'm getting
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more comfortable in terms of dbt and and blood clot management there's a topic with
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blood clots of whether this is a provoked or unprovoked dbt and that determines how long you
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need to take kumadin for and i didn't feel comfortable with it at the time so i had her
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see hematology i probably would feel a lot more comfortable with that now so at the time i had
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her follow up with me in a month um and then three months after that just to kind of make
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sure that she was still feeling okay um things were going well uh and she was able to get
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connected to the specialist that she needed to go to the endocrine so that's it uh leave
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a comment below i'd love to hear from you what is the number one takeaway that you've had from
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this presentation hopefully rechecking your calcium and checking your pth but uh but yeah
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definitely leave me a comment below did you like this video if so if you're on youtube
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