Hyperparathyroidism

Here's a cool jpg of a positive parathyroid scan showing a right lower neck nodule:

GRAHAM: Question for the endocrine guys.  How does one distinguish between primary,secondary, and tertiary hyperparathyroidism?  I have a couple of cases that have been diagnosed by the endrocrinologist as primary, but I suspect secondary or tertiary.

Have you ordered a parathyroid scan to see if there is an adenoma? If positive for an adenoma, then bingo- PRIMARY HYPERPARATHYROIDISM. End of story.

Of course, you should do due diligence and r/o an underlying malignancy (especially bone mets or myeloma), r/o sarcoidosis, r/o tuberculosis, r/o vitamin D deficiency, and make sure that they aren't taking high-dose glucocorticoid therapy plus thiazide diuretics. That's it for the secondary "list". To cover for these, you could get a bone xray (+/- bone scan) for w/u of painful bone syndromes, get a CXR, get a SPEP/SEIP/ BUN+creat, order a vitamin D level... which is a pretty limited and easy workup.