DISORDERS OF THYROID DISORDERS OF THYROID AND PARATHYROID GLAND AND PARATHYROID GLAND AND THEIR MANAGEMENTAND THEIR MANAGEMENT

Prof. Dr. S. N. OjhaProf. Dr. S. N. OjhaM.D. (Ayu.) Phd.M.D. (Ayu.) Phd.Dean & SuperintendentDean & SuperintendentDr. D. Y. Patil College ofDr. D. Y. Patil College ofAyurveda & Research CentreAyurveda & Research CentrePimpri, Pune.Pimpri, Pune.

What is Thyroid?What is Thyroid?The thyroid is a small gland, shaped like a butterfly, The thyroid is a small gland, shaped like a butterfly, located in the lower part of your neck. The main hormones located in the lower part of your neck. The main hormones released by the thyroid are triiodothyronine, (T3) & released by the thyroid are triiodothyronine, (T3) & thyroxine, (T4)thyroxine, (T4)

What Diseases and Conditions Affect the What Diseases and Conditions Affect the Thyroid?Thyroid? Hypothyroidism – An underactive thyroid.Hypothyroidism – An underactive thyroid.Hyperthyroidism – an overactive thyroid.Hyperthyroidism – an overactive thyroid.Goiter – An enlarged thyroid.Goiter – An enlarged thyroid.Thyroid Nodules – Lumps in the thyroid gland.Thyroid Nodules – Lumps in the thyroid gland.Thyroid Cancer – Malignant thyroid nodules or tissue.Thyroid Cancer – Malignant thyroid nodules or tissue.Thyroiditis – Inflammation of the thyroid.Thyroiditis – Inflammation of the thyroid.

Hyperthyroidism :Hyperthyroidism :Hyperthyroidism is a condition where the Hyperthyroidism is a condition where the thyroid gland – the master gland of metabolism thyroid gland – the master gland of metabolism – – is overactive.is overactive.

Causes of HyperthyroidismCauses of Hyperthyroidism1.1. Graves’ disease.Graves’ disease.2.2. ThyroiditisThyroiditis3.3. Autoimmune condition Hashimoto’s Autoimmune condition Hashimoto’s

disease, a temporary hyperthyroidism that disease, a temporary hyperthyroidism that affects womenaffects women

Risk of Graves’ Disease / Risk of Graves’ Disease /

HyperthyroidismHyperthyroidism• Female genderFemale gender• Personal and family history of thyroid Personal and family history of thyroid

problems, autoimmune disease, or endocrine problems, autoimmune disease, or endocrine diseasedisease

• Age 20 and 40Age 20 and 40• Pregnancy – During pregnancy and the year Pregnancy – During pregnancy and the year

after childbirthafter childbirth• Current or former smokerCurrent or former smoker

• Excessive intake of thyroid hormoneExcessive intake of thyroid hormone• Exposure to or excess of iodine/iodine Exposure to or excess of iodine/iodine

drugsdrugs• Certain medical treatmentsCertain medical treatments• Trauma to the thyroidTrauma to the thyroid• Recently experienced major life stressRecently experienced major life stress• Holistic and nutritional factorsHolistic and nutritional factors

Common symptomsCommon symptoms• Goiter, thyroid enlargement, neck sensationsGoiter, thyroid enlargement, neck sensations• Weight and appetite changesWeight and appetite changes• Pregnancy-related problemsPregnancy-related problems• Feeling warm all the time, sweating, thirst, feverFeeling warm all the time, sweating, thirst, fever• Heart and blood pressure changes, fast heart rate, Heart and blood pressure changes, fast heart rate,

abnormal heart rhythmsabnormal heart rhythms• Bowel problems, diarrheaBowel problems, diarrhea• Fatigue, exhaustionFatigue, exhaustion• Muscle and join pain and fatigueMuscle and join pain and fatigue

• Skin changes, blister-like bumps on the Skin changes, blister-like bumps on the forehead and face, hives, itching, vitiligo.forehead and face, hives, itching, vitiligo.

• Skin patches on the shins and legs (Graves’ Skin patches on the shins and legs (Graves’ dermopathy / pretibial myxedema)dermopathy / pretibial myxedema)

• Hair loss and other hair changes.Hair loss and other hair changes.• Finger/nail changes, including swollen, Finger/nail changes, including swollen,

wider fingertips and separation of nail bed wider fingertips and separation of nail bed from skin.from skin.

• Eye problems, including bulging, dryness, Eye problems, including bulging, dryness, pain, redness, puffinesspain, redness, puffiness

• Thinking/cognition problems, including Thinking/cognition problems, including difficult concentrating or making decisions, difficult concentrating or making decisions, memory problems, and racing thoughts.memory problems, and racing thoughts.

• Changes to mood and feelings, including Changes to mood and feelings, including depression, mood swings, uncontrollable depression, mood swings, uncontrollable anger, irrational anger.anger, irrational anger.

• Panic and anxiety, panic attacksPanic and anxiety, panic attacks• Fast reflexes, startling, tremorsFast reflexes, startling, tremors• InsomniaInsomnia

Diagnosing Graves’ DiseaseDiagnosing Graves’ Disease

Clinical Exam.Clinical Exam.• Feel (also known as “palpating”) neckFeel (also known as “palpating”) neck• Palpate for what’s known as “thrill”Palpate for what’s known as “thrill”• Listen for “bruit” during palpationListen for “bruit” during palpation• Test reflexes-hyper responsive reflexes Test reflexes-hyper responsive reflexes

can be a sign of hyperthyroidismcan be a sign of hyperthyroidism• Heart rate, rhythm & blood pressureHeart rate, rhythm & blood pressure• Measure weightMeasure weight• Measure body temperatureMeasure body temperature

• Examine face and neck areaExamine face and neck area• Examine skin for some possible signs of Examine skin for some possible signs of

hyperthyroidismhyperthyroidism• General quantity and quality of hairGeneral quantity and quality of hair• TremorsTremors• Nails and hands for thyroid signsNails and hands for thyroid signs• Evaluate legsEvaluate legs• Examine eyesExamine eyes

Test results that confirm hyperthyroidism Test results that confirm hyperthyroidism

include:include:TSH Test – usually below normal, to undetectableTSH Test – usually below normal, to undetectable

T4/Free T4 Test – Normal to HighT4/Free T4 Test – Normal to High

T3/Free T3 Test – Normal to HighT3/Free T3 Test – Normal to High

Radioactive Iodine Update (RAI-U) TestRadioactive Iodine Update (RAI-U) TestElevated Thyroid Receptor Antibodies (TRAb) / Elevated Thyroid Receptor Antibodies (TRAb) /

Thyroid-Stimulating Immunoglobulin (TSI).Thyroid-Stimulating Immunoglobulin (TSI).

Hyperthyroidism – can be treated with three different Hyperthyroidism – can be treated with three different approaches:approaches:

• Drug treatment with antithyroid drugsDrug treatment with antithyroid drugs• Ablation of the thyroid gland with Radioactive Iodine (RAI)Ablation of the thyroid gland with Radioactive Iodine (RAI)• Surgery to remove all or part of the thyroid.Surgery to remove all or part of the thyroid.

Antithyroid Drug TreatmentAntithyroid Drug Treatment• Methimazole - CarbimazoleMethimazole - Carbimazole• PropylthiouracilPropylthiouracil

Radioactive Iodine TreatmentRadioactive Iodine Treatment- Radioiodine ablationRadioiodine ablation- Radioactive iodine ablationRadioactive iodine ablation- Thyroid ablationThyroid ablation- Ablation therapyAblation therapy- Chemical thyroidectomyChemical thyroidectomy- Chemical surgeryChemical surgery- Radioactive cocktailRadioactive cocktail

Ayurvedic TreatmentAyurvedic Treatment Kanchanar GugguluKanchanar Guggulu Aarogyavardhini RasaAarogyavardhini Rasa Sootshekhar RasaSootshekhar Rasa Dasha moolarishtaDasha moolarishta

Hypothyroidism :Hypothyroidism :

When the thyroid gland is underactive, When the thyroid gland is underactive, improperly formed at birth, surgically improperly formed at birth, surgically removed all or in part, or becomes removed all or in part, or becomes incapable of producing enough thyroid incapable of producing enough thyroid hormone, a person is said to the hormone, a person is said to the hypothyroid. hypothyroid.

CausesCauses Iodine deficiencyIodine deficiency Hashimoto’s thyroiditisHashimoto’s thyroiditis Lack of the thyroid glandLack of the thyroid gland Deficiency of hormones from either the Deficiency of hormones from either the

hypothalamus or the pituitary.hypothalamus or the pituitary. Postpartum thyroiditisPostpartum thyroiditis Sporadic inheritance, sometimes autosomal Sporadic inheritance, sometimes autosomal

recessiverecessive Wolff-Chaikoff effectWolff-Chaikoff effect Lithium-based mood stabilizersLithium-based mood stabilizers

TypeType OriginOrigin DescriptionDescription

PrimaryPrimary Thyroid glandThyroid gland Hashimoto’s thyroiditis & Hashimoto’s thyroiditis & radioiodine therapy for radioiodine therapy for hyperthyroidismhyperthyroidism

SecondarySecondary Pituitary glandPituitary gland Occurs if the pituitary gland Occurs if the pituitary gland does not create enough TSHdoes not create enough TSH

TertiaryTertiary hypothalamushypothalamus Hypothalamus fails to produce Hypothalamus fails to produce TRHTRH

SymptomsSymptomsEarly symptomsEarly symptoms Poor muscle tonePoor muscle tone FatigueFatigue Cold intoleranceCold intolerance DepressionDepression Muscle cramps and joint painMuscle cramps and joint pain ArthritisArthritis GoiterGoiter Thin, brittle fingernailsThin, brittle fingernails Thin, brittle hairThin, brittle hair PalenessPaleness Dry, itchy skinDry, itchy skin Weight gain and water retentionWeight gain and water retention Bradycardia (low heart rate: less than sixty beats per minute)Bradycardia (low heart rate: less than sixty beats per minute) ConstipationConstipation

Late symptomsLate symptoms Slow speech and a hoarse, breaking voice.Slow speech and a hoarse, breaking voice. Dry puffy skin, especially on the faceDry puffy skin, especially on the face Thinning of the outer third of the eyebrows. (sign of Thinning of the outer third of the eyebrows. (sign of

Hertoghe)Hertoghe) Abnormal menstrual cyclesAbnormal menstrual cycles Low basal body temperatureLow basal body temperature

Less common symptomsLess common symptoms Migraine headacheMigraine headache Impaired memoryImpaired memory Anxiety / panic attacksAnxiety / panic attacks UrticariaUrticaria

Impaired cognitive function and inattentivenessImpaired cognitive function and inattentiveness A slow heart rate with ECG changes including low A slow heart rate with ECG changes including low

voltage signals.voltage signals. Reactive (or post-prandial) hypoglycemiaReactive (or post-prandial) hypoglycemia Pericardial effusions may occur.Pericardial effusions may occur. Sluggish reflexesSluggish reflexes Hair lossHair loss Early greying of the hairEarly greying of the hair Anemia caused by impaired hemoglobin synthesisAnemia caused by impaired hemoglobin synthesis Difficulty swallowingDifficulty swallowing Shortness of breath with a shallow and slow Shortness of breath with a shallow and slow

respiratory patternrespiratory pattern

Hypercapnia & hypoxiaHypercapnia & hypoxia Increased sleepIncreased sleep Osteopenia or OsteoporosisOsteopenia or Osteoporosis Irritability and mood instabilityIrritability and mood instability Yellowing of the skinYellowing of the skin Impaired renal functionImpaired renal function Thin, fragile or absent cuticlesThin, fragile or absent cuticles Elevated serum cholesterolElevated serum cholesterol Acute psychosisAcute psychosis Decreased libidoDecreased libido

Decreased sense of taste and smellDecreased sense of taste and smell Puffy face, hands and feetPuffy face, hands and feet Premature wrinkling on the facePremature wrinkling on the face

PediatricPediatric Short statureShort stature Mental retardationMental retardation Short neckShort neck Delayed developmentDelayed development

SeveritySeverity Cardiovascular & psychiatricCardiovascular & psychiatric MyxedemaMyxedemaDiagnostic testingDiagnostic testing Free triiodothyronine (fT3)Free triiodothyronine (fT3) Free levothyroxine (fT4)Free levothyroxine (fT4) Total T3Total T3 Total T4Total T4 24 hour urine free T324 hour urine free T3 antithyroid antibodiesantithyroid antibodies Serum cholesterolSerum cholesterol ProlactinProlactin Testing for anemia, including ferritinTesting for anemia, including ferritin Basal body temperatureBasal body temperature

TreatmentTreatment Levorotatory forms of thyroxin (L-T4)Levorotatory forms of thyroxin (L-T4) Different treatment protocols in thyroid Different treatment protocols in thyroid

replacement therapy:replacement therapy: T4 OnlyT4 Only T4 and T3 in CombinationT4 and T3 in Combination Desiccated Thyroid ExtractDesiccated Thyroid Extract

Ayurvedic TreatmentAyurvedic Treatment Laxmivilas RasaLaxmivilas Rasa Punarnavadi MandurPunarnavadi Mandur Agnitundi VatiAgnitundi Vati AshwagandharishtaAshwagandharishta AmrtarishtaAmrtarishta ShatavariShatavari ChitrakChitrak ChatusparniChatusparni

• Autoimmune Thyroid DiseaseAutoimmune Thyroid Disease

In the case of autoimune thyroid disease, antibodies In the case of autoimune thyroid disease, antibodies either gradually destroy the thyroid, or make it either gradually destroy the thyroid, or make it overactive.overactive.

• Goiter/Thyroid NodulesGoiter/Thyroid Nodules

When the thyroid become enlarged, this is known as a When the thyroid become enlarged, this is known as a goiter.goiter.

• Thyroid CancerThyroid Cancer

• Thyroiditis Thyroiditis

When the thyroid become inflamed, due to bacterial or When the thyroid become inflamed, due to bacterial or viral illness, this is known as thyroiditisviral illness, this is known as thyroiditis

Treatments – Surgery, Thyroid drugsTreatments – Surgery, Thyroid drugs

Parathyroid glandParathyroid gland

The parathyroid glands are small The parathyroid glands are small endocrine gland in the neck that endocrine gland in the neck that produces parathyroid hormone. produces parathyroid hormone.

Most people have four parathyroid Most people have four parathyroid glands, but some people have six or glands, but some people have six or even eighteven eight

HypoparathyroidismHypoparathyroidism

It is decreased function of parathyroid It is decreased function of parathyroid glands, leading to decreased levels of glands, leading to decreased levels of parathyroid hormone (PTH).parathyroid hormone (PTH).

CausesCauses Removal of the parathyroid glands in thyroid surgery Removal of the parathyroid glands in thyroid surgery

(thyroidectomy)(thyroidectomy) Autoimmune.Autoimmune. Hemochromatosis Hemochromatosis Chromosome 22q11 microdeletion syndrome (other Chromosome 22q11 microdeletion syndrome (other

names: DiGeorge syndrome Schprintzen syndrome, names: DiGeorge syndrome Schprintzen syndrome, velocardiofacial syndrome).velocardiofacial syndrome).

Magnesium deficiencyMagnesium deficiency DiGeorge syndrome, absence of the parathyroid DiGeorge syndrome, absence of the parathyroid

glands at birth.glands at birth. Idiopathic, occasionally familialIdiopathic, occasionally familial

Signs and SymptomsSigns and Symptoms

Tingling lips, fingers, and toes Tingling lips, fingers, and toes Muscle cramps Muscle cramps Pain in the face, legs, and feet Pain in the face, legs, and feet Abdominal pain Abdominal pain Dry hair Dry hair Brittle nails Brittle nails Dry, scaly skin Dry, scaly skin Cataracts Cataracts Weakened tooth enamel (in children) Weakened tooth enamel (in children) Muscle spasms called tetany Muscle spasms called tetany Convulsions (seizures) Convulsions (seizures)

Additional symptomsAdditional symptoms Painful menstruation Painful menstruation Hand or foot spasmsHand or foot spasms Decreased consciousnessDecreased consciousness Delayed or absent tooth formationDelayed or absent tooth formation

DiagnosisDiagnosis1.1. Measurement of calcium Measurement of calcium

2.2. Serum albumin Serum albumin

3.3. PTH in blood. PTH in blood.

4.4. E.C.G. E.C.G.

Differential diagnoses are: Differential diagnoses are:

PseudohypoparathyroidismPseudohypoparathyroidism PseudopseudohypoparathyroidismPseudopseudohypoparathyroidism Vitamin D deficiency or hereditary Vitamin D deficiency or hereditary

insensitivity to this vitamin (X-linked insensitivity to this vitamin (X-linked dominant).dominant).

MalabsorptionMalabsorption Kidney diseaseKidney disease Medication: Steroids, diuretics, some Medication: Steroids, diuretics, some

antiepileptics.antiepileptics.

TreatmentTreatment1.1. Intravenous calcium Intravenous calcium

Long-term treatmentLong-term treatment Calcium and Vitamin D 3Calcium and Vitamin D 3 TeriparatideTeriparatide

Possible ComplicationsPossible Complications Tetany can lead to a blocked airwayTetany can lead to a blocked airway Stunted growth, malformed teeth, slow mental Stunted growth, malformed teeth, slow mental

developmentdevelopment Overtreatment with vitamin D and calcium can Overtreatment with vitamin D and calcium can

cause hypercalcemiacause hypercalcemia

PseudohypoparathyroidismPseudohypoparathyroidism

Pseudohypoparathyroidism is a condition Pseudohypoparathyroidism is a condition caused by resistance to the parathyroid caused by resistance to the parathyroid hormone. hormone.

Patients have a low serum calcium and high Patients have a low serum calcium and high phosphate, but the parathyroid hormone level phosphate, but the parathyroid hormone level (PTH) is appropriately high.(PTH) is appropriately high.

TypesTypes Type 1 a pseudohypoparathyroidismType 1 a pseudohypoparathyroidism Type 1 b pseudohypoparathyroidism lacks the Type 1 b pseudohypoparathyroidism lacks the

physical appearance of type 1 a biochemically similarphysical appearance of type 1 a biochemically similar Type 2 pseudohypoparathyroidism also lacks the Type 2 pseudohypoparathyroidism also lacks the

physical appearance of type 1 a.physical appearance of type 1 a.

PresentationPresentation Features of hypocalcaemia Features of hypocalcaemia Including; carpo-pedal spasm, tetany, muscle Including; carpo-pedal spasm, tetany, muscle

cramps and seizures. cramps and seizures. Type 1 a Pseudohypoparathyroidism is clinically Type 1 a Pseudohypoparathyroidism is clinically

manifest by blunting of fourth and fifth manifest by blunting of fourth and fifth metacarpals, short stature, obesity, developmental metacarpals, short stature, obesity, developmental delay.delay.

Biochemical FindingsBiochemical Findings HypocalcemiaHypocalcemia HyperphosphatemiaHyperphosphatemia Elevated parathyroid hormone Elevated parathyroid hormone

HypocalcemiaHypocalcemia

Muscle spasmMuscle spasm Carpopedal spasmCarpopedal spasm facial grimacingfacial grimacing Layrngeal spasmLayrngeal spasm ConvulsionConvulsion Respiratory arrest may occurRespiratory arrest may occur Increase intracranial pressureIncrease intracranial pressure IrritabilityIrritability DepressionDepression PsychosisPsychosis ArrhythmiasArrhythmias Intestinal crampsIntestinal cramps Chvostek’s or Trousseaus SignChvostek’s or Trousseaus Sign

TreatmentTreatment Replacement with Vit. D or CalcitriolReplacement with Vit. D or Calcitriol High oral calcium intakeHigh oral calcium intake Thiazide diureticsThiazide diuretics

Ayurvedic TreatmentAyurvedic Treatment Godanti Godanti Praval PanchamrutaPraval Panchamruta

HyperparathyroidismHyperparathyroidismHyperparathyroidism is overactivity of the parathyroid glands Hyperparathyroidism is overactivity of the parathyroid glands resulting in excess production of parathyroid hormone (PTH)resulting in excess production of parathyroid hormone (PTH)

ClassificationClassification Primary HyperparathyroidismPrimary Hyperparathyroidism

It results from a hyper function of the parathyroid glands It results from a hyper function of the parathyroid glands themselves. There is over secretion of PTH due to adenoma, themselves. There is over secretion of PTH due to adenoma, hyperplasia or rarely, carcinoma of the parathyroid glands.hyperplasia or rarely, carcinoma of the parathyroid glands.

Secondary hyperparathyroidismSecondary hyperparathyroidismSecondary hyperparathyroidism is the reaction Secondary hyperparathyroidism is the reaction of the parathyroid glands to a hypocalcemia of the parathyroid glands to a hypocalcemia caused by something other than a parathyroid caused by something other than a parathyroid pathology, e.g. chronic renal failure.pathology, e.g. chronic renal failure.

Tertiary HyperparathyroidismTertiary HyperparathyroidismTertiary hyperparathyroidism is a state of Tertiary hyperparathyroidism is a state of excessive secretion of parathyroid hormone excessive secretion of parathyroid hormone (PTH) after a long period of secondary (PTH) after a long period of secondary hyperparathyroidism and resulting in hyperparathyroidism and resulting in hypercalcemia.hypercalcemia.

EtiologyEtiologyPrimary hyperparathyroidismPrimary hyperparathyroidism

1. benign parathyroid adenoma1. benign parathyroid adenoma

2. multiple endocrine neoplasia2. multiple endocrine neoplasia

Secondary hyperparathyroidismSecondary hyperparathyroidism

Due to excessive secretion of parathyroid Due to excessive secretion of parathyroid hormone (PTH) by parathyroid glands in hormone (PTH) by parathyroid glands in response to hypocalcemia and/or response to hypocalcemia and/or hyperphosphatemia, usually due to chronic hyperphosphatemia, usually due to chronic renal failure.renal failure.

Tertiary hyperparathyroidismTertiary hyperparathyroidism

Caused by long lasting disorders of the calcium Caused by long lasting disorders of the calcium feedback control system.feedback control system.

Symptoms and signsSymptoms and signs

Asymptomatic hyperparathyroidismAsymptomatic hyperparathyroidism

Coincidental finding of hypercalcemiaCoincidental finding of hypercalcemia

Symptomatic HyperparathyroidismSymptomatic Hyperparathyroidism

Most of the symptoms of parathyroid disease are Most of the symptoms of parathyroid disease are “neurological” “neurological”

weakness and fatigue, weakness and fatigue,

depression, aches and pains, depression, aches and pains,

decreased appetite, decreased appetite,

feelings of nausea and vomiting, feelings of nausea and vomiting,

constipation, constipation,

polyuria, polyuria,

polydipsia, polydipsia,

cognitive impairment, cognitive impairment,

kidney stones and kidney stones and

osteoporosis. osteoporosis.

Symptoms of hyperparathyroidism can be Symptoms of hyperparathyroidism can be remembered by the rhyme “moans, groans, remembered by the rhyme “moans, groans, stones, bones, and psychiatric overtones” :stones, bones, and psychiatric overtones” :

““moans” (complaints of not feeling well)moans” (complaints of not feeling well) ““groans” (abdominal pain, gastroesophageal groans” (abdominal pain, gastroesophageal

reflux)reflux) ““stones” (kidney)stones” (kidney) ““bones” (bone pain)bones” (bone pain) ““psychiatric overtones” (lethargy, fatigue, psychiatric overtones” (lethargy, fatigue,

depression, memory problems)depression, memory problems)

Laboratory testsLaboratory tests

Serum calciumSerum calcium In cases of primary, tertiary In cases of primary, tertiary

hyperparathyroidism hyperparathyroidism increased PTH increased PTH consequently leads to increased consequently leads to increased serum calcium serum calcium (hypercalcemia)(hypercalcemia)

In secondary hyperparathyroidism In secondary hyperparathyroidism effectiveness effectiveness of PTH is reduced.of PTH is reduced.

Serum phosphorusSerum phosphorus Primary hyperparathyroidism levels are Primary hyperparathyroidism levels are

abnormally low abnormally low Secondary hyperparathyroidism serum Secondary hyperparathyroidism serum

phosphorus levels are generally elevatedphosphorus levels are generally elevated

DiagnosisDiagnosis

PTHPTH Serum calciumSerum calcium Likely typeLikely type

highhigh highhigh Primary hyperparathyroidismPrimary hyperparathyroidism

highhigh Low or normalLow or normal Secondary hyperparathyroidismSecondary hyperparathyroidism

Tertiary hyperparathyroidism has a high PTH and high serum Tertiary hyperparathyroidism has a high PTH and high serum

calcium.calcium.

PTH immunoassayPTH immunoassay

Alkaline phosphataseAlkaline phosphatase

Alkaline phosphatese levels are not elevated in all types of Alkaline phosphatese levels are not elevated in all types of hyperparathyroidismhyperparathyroidism

Treatment and monitoringTreatment and monitoring SurgerySurgery

If surgery is not available, the following If surgery is not available, the following should be monitoredshould be monitored

Calcium levelCalcium level Bone densityBone density Check for kidney stonesCheck for kidney stonesPreventionPrevention ExerciseExercise Vitamin D-Adequate amounts of vitamin D aid Vitamin D-Adequate amounts of vitamin D aid

in calcium absorption.in calcium absorption. Stay hydratedStay hydrated No smokingNo smoking

HypercalcemiaHypercalcemiaFatigueFatigue

DepressionDepression

Mental ConfusionMental Confusion

AnorexiaAnorexia

NauseaNausea

VomitingVomiting

ConstipationConstipation

Increased urinationIncreased urination

Cardiac arrythmiasCardiac arrythmias

TreatmentTreatment Restricted Dietary CalciumRestricted Dietary Calcium RehydrationRehydration Forced DiuresisForced Diuresis CalcitoninCalcitonin Anti resorptive agents (bisphosphonates)Anti resorptive agents (bisphosphonates) Phosphate therapyPhosphate therapy