PANCE Blueprint Endocrinology (6%)


Patient will present as → a 62-year-old woman presents complaining of joint pain, polyuria, polydipsia, and generalized fatigue. The woman reports a history of recurrent kidney stones and depression. Radiographs show osteopenia and subperiosteal resorption on the phalanges (Bones, stones, abdominal groans and psychic moans)

Most patients with calcium levels < 12 are asymptomatic.  Symptoms usually begin as the calcium level rises above 12, and the symptoms will worsen as the calcium level continues to rise.   Initially, patients may complain of nausea and vomiting with a loss of appetite.  They may feel muscle weakness and fatigue.  Constipation may be present. As the calcium level rises, they may become confused and lethargic.  Polyuria can occur with renal failure. Cardiac arrhythmias can occur and even coma.

Hyperparathyroidism always = ↑ PTH 

Hyperparathyroidism has two cause: primary and secondary 

  1. Primary = ↑ PTH usually caused by a PTH secreting parathyroid ADENOMA
  2. Secondary =↑ PTH by a physiologic response to hypocalcemia or vitamin D deficiency. Chronic kidney disease is the most common cause of secondary hyperparathyroidism.
  • Osteoporosis, renal calculi, bone pain, GI symptoms, depression, psychosis, fatigue.

Bones, Stones, Groans and Psychic Moans

  1. Bone loss from ↑ PTH and calcium absorption from bones = pain in bones
  2. Renal loss of calcium and phosphate  = kidney stones
  3. Increase GI absorption of calcium and abdominal cramps = groans
  4. Irritability, psychosis, and depression = moans
Serum Ca
Serum Phos
Common Cause
Ectopic PTH
Vit D malabsorption
celiac disease, other GI disease
↓ D with no phosphate excretion from the kidney.
renal failure, pseudo hypoparathyroidism

↑ Calcium is the most common metabolic abnormality associated with hyperparathyroidism

↑ PTH secretion from the parathyroid raises the blood calcium level by:

  1. breaking down the bone (where most of the body's calcium is stored) and causing calcium release
  2. increasing the body's ability to absorb calcium from food from the GI tract
  3. increasing the kidney's ability to hold on to calcium that would otherwise be lost in the urine

This results in increased serum and urinary calcium, osteoporosis, and renal calculi.


  • ↑ Calcium is the most common metabolic abnormality.
  • Blood: ↑ PTH, ↑ Calcium, ↓ phosphorus
  • Urine: hyperphosphaturia, hypercalciuria this makes sense because all that calcium and phosphorus have to go somewhere, so they go out through the kidneys and into the urine.

Remove the PARATHYROID adenoma, subtotal parathyroidectomy (3 1/2 of gland removed) or total parathyroidectomy.

  • If it is secondary then once you replace the cause (Vitamin D and Calcium supplementation) you will have fixed the problem.
  • If the calcium is very high you will need to treat with IV fluids, Furosemide or Calcitonin.
  • May need to treat osteoporosis with Bisphosphonates.

Calcium regulation and PTH

IM_MED_PrimaryHyperparathyroidism_V1.2_ASSETS_ This condition is characterized by an increase in parathyroid hormone (PTH) secretion, which regulates serum calcium and phosphorus levels by stimulating bone resorption of calcium, renal tubular reabsorption of calcium, and the activation of Vitamin D.

Primary Hyperparathyroidism Picmonic

parathyroid-gland_5110_1472585798 The parathyroid gland is a series of four small glands located in the neck on the rear surface of the thyroid gland. It serves primarily in calcium homeostasis and has a blood calcium sensor that detects when blood calcium levels are abnormally low. It responds by releasing parathyroid hormone (PTH) which stimulates osteoclasts into action. Osteoclasts resorb bone and release a large amount of calcium. This calcium enters the blood and results in increased blood calcium levels. PTH can also activate vitamin D by promoting the activity of an enzyme that converts inactive vitamin D to active vitamin D

Parathyroid Gland Overview Picmonic

Question 1
Which of the following laboratory results is most consistent with a diagnosis of primary hyperparathyroidism?  
serum calcium 11.5 mg/dL (normal 8.5 to 10.5 mg/dL)
ionized calcium 3.2 mg/dL (normal 4.6 to 5.3 mg/dL)
Ionized calcium levels are invariably increased in primary hyperparathyroidism, typically greater than 5.4 mg/dL.
serum magnesium 1.1 mEq/L (normal 1.3 to 2.1 mEq/L)
Serum magnesium is not affected in primary hyperparathyroidism.
serum phosphate 3.0 mg/dL (normal 2.5 to 4.5 mg/dL)
Serum phosphate is usually low in primary hyperparathyroidism.
Question 1 Explanation: 
Hypercalcemia (greater than 10.5 mg/dL) is the hallmark of primary hyperparathyroidism.
There is 1 question to complete.
Shaded items are complete.

Lesson Intro Video

Please login to get access to the quiz
Diseases of the Thyroid Gland (PEARLS) (Prev Lesson)
(Next Lesson) Hypoparathyroidism
Back to PANCE Blueprint Endocrinology (6%)