Case History

Ms M is a 52-year-old postmenopausal African American woman who reported to the family practice clinic as a new patient for her Papanicolaou test and referral for a screening mammogram. She had no complaints and reported no history of abnormal findings on the aforementioned diagnostic tests, although she was uncertain when these tests were last performed.

Ms M is a college graduate and a reliable historian. She has never been married or pregnant, is not sexually active, and has no history of sexually transmitted infections. Ms M reported short-term use of contraception during perimenopause and transdermal hormone replacement therapy due to severe vasomotor symptoms. She has infrequent night sweats and does not wish to resume hormone replacement therapy. Her last menstrual period was 7 years earlier.

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Ms M has never smoked.  She drinks one cup of coffee per day and does not drink alcohol.  She neither abuses prescription medications nor uses illicit drugs. She has no known drug or food allergies and takes no prescription or over-the-counter medications. Her medical history is significant for multiple uterine fibroids for which she underwent myomectomy. Although she does not recall the date or year of her surgery, she does recall that the procedure and hospital stay were uneventful. She underwent colonoscopy at 49 years of age because of rectal bleeding and constipation. Benign polyps were identified, and the gastroenterologist recommended follow-up in 10 years as she had no family history of colorectal cancer. Her family history is significant for her mother having an abnormal Papanicolaou test result that was managed with “freezing of her cervix.” Her maternal grandaunt died in her late 50s after a diagnosis of late-stage breast cancer.

Ms M received all her childhood immunizations, the hepatitis B vaccine series, and the hepatitis A vaccine.  She undergoes annual influenza vaccination. She is unsure of the date of her last tetanus vaccine.

Physical Examination and Plan

Ms M’s blood pressure was measured at 122/72 mm Hg.  Her height is 5 ft 8 in and her weight is 185.6 lb; body mass index (BMI) is calculated at 28.2 kg/m2. The remainder of her physical examination was unremarkable. Her plan of care included a Papanicolaou test, since she was unable to recall when she last underwent testing, comprehensive metabolic panel, lipids, thyroid-stimulating hormone, urinalysis, and referral for screening mammogram. She received tetanus vaccine at this visit.

Abnormal Laboratory Results

Two weeks after her initial visit, Ms M’s primary care provider (PCP) called and informed her that her test results were within normal limits except for serum calcium, which was elevated at 10.6 mg/dL (reference range, 8.5-10.0 mg/dL). Because of her hypercalcemia, a parathyroid hormone (PTH) level was requested and was found to be elevated at 136.4 pg/dL  (reference range, 14.0-72.0 pg/dL). When asked about possible symptoms of primary hyperparathyroidism (Table), Ms M admitted experiencing fatigue, which she attributed to her work schedule and personal problems.

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As a result of her elevated calcium and PTH levels, Ms M was referred for osteoporosis screening and consultation with an endocrinologist, who advised that she undergo a sestamibi scan of her parathyroid. The result of the dual x-ray absorptiometry test was osteopenia of L1 to L4 and the femoral necks bilaterally.  She was instructed to increase her daily intake of calcium to 1200 mg, take over-the-counter vitamin D3 1000 IU/d, and undergo repeat dual x-ray absorptiometry testing in 2 years.

Following further laboratory testing, Ms M was found to be deficient in vitamin D at 13.3 ng/mL (reference range, 30-80 ng/mL); she was prescribed ergocalciferol (vitamin D2) 50,000 IU weekly for 8 weeks, followed by 3000 IU/d. Three months later, repeat vitamin D level was 16.9 ng/mL and calcium was normal at 9.4 ng/mL.  She was advised to repeat her regimen of ergocalciferol 50,000 IU once per week for 8 weeks followed by 3000 IU/d.

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Sestamibi scan of the parathyroid gland revealed a suspected right lower adenoma measuring <1 cm. Ultrasound of the parathyroid and thyroid confirmed the parathyroid adenoma and revealed thyroid cysts and nodules that were not considered suspicious. Ms M was advised to return for follow-up in one year. She kept her appointment with the endocrinologist. As there was no sign of lymphadenopathy on physical examination, the endocrinologist recommended repeat thyroid ultrasound and follow-up only if she experienced changes in her condition. The endocrinologist agreed with the PCP’s plan that Ms M should undergo removal of the parathyroid adenoma. Ms M followed up with a surgical oncologist and was scheduled for excision of the parathyroid adenoma.