Surgery MCQs Q13

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ENDOCRINE • SURGERY • UROLOGY

A 52-year-old woman is evaluated for recurrent episodes of flank pain. Imaging reveals multiple renal calculi. Laboratory tests show elevated serum calcium and elevated parathyroid hormone (PTH) levels.

What is the most common manifestation of primary hyperparathyroidism?

A Bone disease

B Peptic ulceration

C Constipation

D Renal stone disease

E Polyuria

D. Renal stone disease. Nephrolithiasis (calcium stones) remains the most common symptomatic clinical manifestation of primary hyperparathyroidism in modern medical practice.

Decoding the Stem

1

CLUE "↑Calcium + ↑PTH"

TRANS Confirms Primary Hyperparathyroidism (autonomous hormone production).

2

CLUE "Most common manifestation"

TRANS Asks for the prevalent clinical finding among symptomatic patients.

Explanation

D. Renal stone disease: Correct. PTH increases bone resorption and renal calcium reabsorption, but the sheer load of filtered calcium leads to hypercalciuria. Stones (calcium oxalate/phosphate) are the most common symptom.

A. Bone disease: Incorrect. While classic (Osteitis fibrosa cystica), it is now rare due to early diagnosis. Osteoporosis is more common than actual fibrosa cystica today.

B. Peptic ulceration: Incorrect. A known but rare association linked to hypercalcemia-induced gastrin release.

C. Constipation: Incorrect. A non-specific feature of hypercalcemia (the "groans"); common but less diagnostic/specific than stones.

E. Polyuria: Incorrect. Hypercalcemia can cause nephrogenic diabetes insipidus, but this is less common than stone formation.

🧠 High-Yield Pearls

Parameter	Finding	Significance
Primary Cause	Parathyroid Adenoma	~85% of cases (Solitary)
Classic Mnemonic	Stones, Bones, Groans	Kidney, Skeletal, GI effects
Labs	↑Ca, ↓Phos, ↑PTH	Classic biochemical profile

Integrated Clinical Questions

1. Most common cause of primary hyperparathyroidism?

Answer: Parathyroid adenoma (usually solitary).

2. Classic X-ray finding in bone disease?

Answer: Subperiosteal bone resorption, most easily seen in the middle phalanges.

3. Type of stones most commonly formed?

Answer: Calcium oxalate and calcium phosphate stones.

4. Why does polyuria occur in hypercalcemia?

Answer: Hypercalcemia causes ADH resistance at the collecting duct (Nephrogenic Diabetes Insipidus).

5. Definitive treatment for symptomatic patients?

Answer: Parathyroidectomy.

⚡ Exam Pearls

• Modern presentation: Stones > Bones (Bone disease is becoming rare).
• Diagnosis is biochemical: Hypercalcemia with inappropriately high/normal PTH.
• High calcium + Low phosphate = Primary Hyperparathyroidism.
• "Psychiatric overtones" refer to depression, fatigue, and memory loss.

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