Calcium And Bone Metabolism Questions

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Question 1 of 19
1. Question
Which of the following statements regarding treatment failure in osteoporosis is inaccurate?
- A single incident fragility fracture during treatment implies treatment failure.
- Sustaining two or more incident fragility fractures.
- Less than 25% decline in serum antiresorptive markers and a significant decline in bone mineral density.
- Skull fractures do not represent fragility fractures and should not be considered as treatment failure.
- Typically, after instituting osteoporosis treatment, the rate of vertebral fractures is relatively lower than that of hip fractures.
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Question 2 of 19
2. Question
Which of these pairs of sequential therapy for osteoporosis is suboptimal.
- Teriparatide after alendronate
- Alendronate after teriparatide
- Denosumab after teriparatide
- Teriparatide after denosumab
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Question 3 of 19
3. Question
A 67-year-old female with primary osteoporosis has been on oral alendronate for 5 years, with a statistically significant improvement in her BMD scores at the hip and lumbar vertebra. She follows fall preventive precautions and is on the recommended dose of calcium and vitamin D. Her current T score at the hip is less than -2.6. She has not sustained any fracture since starting anti-resorptive therapy. She has a high frailty score (SF-36) and has fallen twice within the past year. What would you suggest at this time?
- An additional 5 years of oral alendronate
- A bisphosphonate holiday
- Stop alendronate and start raloxifene
- Switch to an anabolic agent like teriparatide
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Question 4 of 19
4. Question
Which of the following is not an indication for antiresorptive therapy in patients with Paget’s disease.
- High output cardiac failure (Congestive heart failure)
- Hypocalcemia due to prolonged immobilization
- Persistent bone pain
- Pagetoid lesions at weight bearing joints
- Planned orthopedic procedure involving a bone with active pagetoid changes.
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Question 5 of 19
5. Question
A 72-year-old woman with osteoporosis on alendronate presents to her primary care provider’s office with right-sided thigh pain. Patient has been on alendronate for 8 years due to her high fracture risk. A plain radiograph of the right femur and hip joint is significant for a localized area of periosteal thickening of the lateral cortex of the right femur. What should the PCP recommend?
- Continue alendronate
- Switch from alendronate to denosumab
- Hold alendronate and refer to an orthopedic surgeon.
- Switch from alendronate to denosumab and refer to an orthopedic surgeon.
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Question 6 of 19
6. Question
A 68-year-old is recently diagnosed with Paget’s disease of bone, which of these treatments is guideline recommended for the management of Paget’s disease of bone (PDB)?
- Calcitonin
- Teriparatide
- Risedronate 30mg per day for 6 months
- Alendronate 40mg per day for 6 months
- Alendronate 70mg per day for 12months and reevaluate disease status with a bone scan.
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Question 7 of 19
7. Question
A 72-year-old man presents to the endocrinology practice with a 2-year history of multiple fragility fractures involving 3 thoracic vertebral bodies, rib fractures, and persistent muscle soreness. She endorses persistent lower extremity weakness as well.
```
Alkaline phosphatase 203 u/L (60 to 120)

PTH 60ng/L (15 to 65)

25 Hydroxyvitamin D level 42 (30 to 100ng/mL)

1,25 Hydroxyvitamin D level 12 (15 to 55pg/mL)

Calcium 9.8 mg/dL (8.5 to 10.2)

Phosphorus 0.8 mg/dL (2.5 to 4.5)
```
What is this patient’s most likely diagnosis?
- X linked hypophosphatemic rickets
- Ectopic secretion of fibroblast growth factor 23
- Vitamin D receptor blocking antibodies
- Autosomal dominant hypophosphatemic rickets
- Osteomalacia due to chronic hepatic disease.
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Question 8 of 19
8. Question
A 32-year-old woman is admitted to the emergency room with symptomatic moderate hypercalcemia. Serum calcium of 12.3 mg/dL (8.5 to 10.3), phosphorus of 4.1 mg/dL (2.5 to 4.5). She has a 1,25 dihydroxy vitamin D level more than twice the upper limit of normal. PTH is 8 pg/mL (15 to 65). Her 24hour urinary calcium is elevated at 680mg (100 to 300). What would you recommend next?
- IV Zoledronic acid and IV hydration
- SQ Denosumab and IV hydration
- Prednisone and IV hydration
- IV Zoledronic acid, IV hydration and refer to surgery for parathyroidectomy
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Question 9 of 19
9. Question
There are multiple hormones involved in calcium physiology, which of these pairs comparing a hormone with its mechanism of action is inaccurate?
- Parathyroid hormone – Activation of osteoblasts
- Vitamin D – Increased renal calcium absorption
- Fibroblast growth factor 23 – Increased intestinal calcium and phosphate absorption.
- Calcitonin – Inhibition of osteoclasts
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Question 10 of 19
10. Question
A 28-year-old woman with recently diagnosed primary hyperparathyroidism is now 14 weeks pregnant. What is your concern for the patient’s unborn offspring, after delivery?
- Hypercalcemia
- Hypocalcemia
- Nephrolithiasis
- Metabolic bone disease
- Calciphylaxis
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Question 11 of 19
11. Question
A 56-year-old woman undergoes parathyroidectomy for primary hyperparathyroidism. His pre-incision PTH was elevated at 160 (20-65), his intraoperative PTH fell by less than 5% after removal of two parathyroids, it eventually decreased by more than 50% after removal of the third parathyroid gland with a PTH level of 78. The fourth parathyroid gland was normal in size and attached to the superior right lobe of the thyroid gland. What is your interpretation of this sequence of intraoperative events?
- Patient was not cured of primary hyperparathyroidism
- Patient has achieved operative cure
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Question 12 of 19
12. Question
An otherwise healthy 86 year old woman undergoes a successful single parathyroid adenomectomy which lasted 30 minutes. Her pre-operative PTH was 75 (20-63), serum calcium of 10.8 (8.3-10.2), albumin 3.9, ionized calcium 5.5 (4.0-5.2), and 26 hydroxyvitamin D level of 20 (30-100).
She reports to the emergency room 3 days after surgery with persistent acral paresthesias and is noted to have a positive Trousseau’s sign. What is the most likely cause of her postoperative hypocalcemia?
- Vitamin D deficiency
- Permanent hypoparathyroidism
- Hypomagnesemia
- Hypoalbuminemia
- Transient hypoparathyroidism.
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Question 13 of 19
13. Question
An otherwise healthy 80-year-old female with a history of stage IIIa chronic kidney disease presents to the ED with severe pain in the lower back after sustaining a fall from a standing height. Vital signs are stable with an unremarkable physical exam except for point tenderness over the L4 spinous process. Her serum calcium is 10.0 (8.3-10.2), albumin 4.0, PTH 66 (20-63). She has an L4 vertebral fracture noted on a plain radiograph of the lumbosacral spine.
What is the most likely diagnosis?
- Normocalcemic primary hyperparathyroidism
- Primary hyperparathyroidism with concomitant hypovitaminosis D
- Secondary hyperparathyroidism due to vitamin D deficiency
- Parathyroid carcinoma.
- Secondary hyperparathyroidism due to chronic kidney disease
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Question 14 of 19
14. Question
A 45-year-old woman with end-stage renal disease on chronic hemodialysis presents to the emergency with a dark eschar on her right anterolateral shin which has progressively increased in size over the past few weeks. She has a history of multiple fragility fractures involving the thoracic spine. Her serum calcium is 11.5 (8.3-10.2), albumin 4.0, PTH 926 (20-63) and phosphorus 7.2 (<4.5). She is currently on cinacalcet and sevelamer (phosphate binder). What is the next step in the management of this patient?
- Subtotal parathyroidectomy (3 and half parathyroid gland resection)
- Total parathyroidectomy
- Check 25 hydroxy vitamin D levels and consider calcitriol in addition to cinacalcet
- Increase the dose of cinacalcet and phosphate binders (to reduce hyperphosphatemia induced PTH secretion).
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Question 15 of 19
15. Question
An obese patient with a short stature and dimples over the 4th and 5th metacarpophalangeal joints upon making a fist, presents to your office for an annual physical. Which of these biochemical panels is suggestive of pseudopseudohypoparathyroidism?
Serum Calcium Serum Phosphate Serum PTH
1 LOW HIGH LOW
2 LOW HIGH LOW
3 LOW HIGH HIGH
4 NORMAL LOW HIGH
5 NORMAL NORMAL NORMAL
- option 1
- option 2
- option 3
- option 4
- option 5
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Question 16 of 19
16. Question
A patient is referred to you by an ENT surgeon due to refractory hypocalcemia. The patient is a 23-year-old female who underwent an extensive total thyroidectomy for an aggressive papillary thyroid cancer 6 months earlier. She developed permanent postoperative hypoparathyroidism as a result of the extensive surgery. Her current regimen includes 2 grams of calcium carbonate 4 times a day and calcitriol 0.25mcg twice daily. She endorses chronic constipation which has not improved with fiber supplementation and increased fluid intake. She has no subjective symptoms or objective clinical findings for hypocalcemia. Her 24hour urinary calcium excretion is 410 (<300mg per day). Serum calcium is 8.1 (8.3-10.2), albumin 4.0, PTH (not checked by the referring surgeon), phosphorus 4.4 (2.5 -4.5) and a normal serum magnesium.
What would you be your next step in the management of this patient?
- Assess parathyroid hormone levels to get a more complete biochemical picture.
- Change from calcitriol to a longer acting vitamin D metabolite like alfacidiol
- Reduce the dose of calcium carbonate and increase that of calcitriol.
- Start thiazide diuretics to reduce urinary calcium excretion.
- Consider recombinant parathyroid hormone (Natpara)
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Question 17 of 19
17. Question
Which of these medications has not shown a demonstrable effect in reducing vertebral, nonvertebral and hip fractures?
- Risedronate
- Alendronate
- Zoledronic acid
- Teriparatide
- Denosumab
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Question 18 of 19
18. Question
23-year-old female was evaluated by her primary care doctor during an annual physical exam. Her medical history is significant for recurrent acute pancreatitis and cholelithiasis. She was noted to have serum calcium of 11.2 (8.3-10.2), albumin 3.9, ionized calcium 5.4 (4.0-5.2), PTH 57 (20-63) and 25 hydroxyvitamin D level of 42(30-100). Her estimated GFR 62 and a fractional calcium to creatinine excretion ratio is markedly suppressed at 0.005. What is this patient’s diagnosis?
- Lithium ingestion leading to a lower set point for the parathyroid calcium-sensing receptors.
- Familial hypocalciuric hypercalcemia
- Primary hyperparathyroidism
- Tertiary hyperparathyroidism due to stage II CKD
- Stimulating anti-calcium sensing receptor antibodies
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Question 19 of 19
19. Question
A 76-year-old female with no significant past medical history. Presented with a 4-month history of generalized bone pain. She had no other symptoms. Physical exam was significant for 2+ pallor and moist mucous membranes. Her laboratory investigations were remarkable for serum calcium of 19 (8.3-10.2), albumin 3.9, ionized calcium 4.2 (4.0-5.2), PTH 25 (20-63) and Cr of 0.5. The patient was diagnosed with multiple myeloma due to hypercalcemia, multiple lytic bone lesions, and an abnormal serum protein electrophoresis.
What should be done next?
- Start IV crystalloids and calcitonin
- Start IV crystalloids and administer IV bisphosphonates
- Consider dialysis if there is no response to medical therapy
- Monitor serum calcium levels
- Patient has spuriously normal ionized calcium due to myeloma proteins, monitor serum calcium levels.
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Calcium and Bone Metabolism Questions

Calcium and Bone Metabolism Questions

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	Serum Calcium	Serum Phosphate	Serum PTH
1	LOW	HIGH	LOW
2	LOW	HIGH	LOW
3	LOW	HIGH	HIGH
4	NORMAL	LOW	HIGH
5	NORMAL	NORMAL	NORMAL