Snapshot A 45-year-old woman presents with pain and achiness in her joints and bones, as well as confusion and a dulled mental state. She also has had recurrent episodes of kidney stones, and in the ED they found QTc shortening on her EKG. She is currently requesting morphine for her GI pain. Introduction Associated with MEN I (parathyroid, pancreatic tumor, pituitary adenoma) and IIa (medullary carcinoma of the thyroid, pheochromocytoma, hyperplasia of the parathyroid) ret mutation Right inferior gland is most common location hyperactivity in one gland results in atrophy of remaining 3 Carcinoma is rare Presentation Symptoms "bones, stones, moans, and groans" see hyperparathyroidism Evaluation Histology sheets of chief cells no adipose tissue Serology serum calcium level elevated, PTH increased, and phosphate decreased see hyperparathyroidism Technetium-99m-sestamibi radionuclide scan localizes mass Treatment Surgical adenoma excision hungry bones syndrome increased bone breakdown and leads to increased osteoblast activity in response to increased osteoclast activity from PTH when PTH decreases, osteoblast activity remains to rebuild the excess bone breakdown this causes hypocalcemia that is transient Chvostek's sign Trosseau's sign QTc lenthening Acute hypercalcemia IV fluids loop diuretic (debatable as it can cause other electrolyte abnormalities) calcitonin bisphosphonate - long-term inhibition