Running head: CASE STUDY 1

Case Study 1 for Advanced Pathophysiology

Lesley Davidson
Wright State University

CASE STUDY 1

Case Study 1 for Advanced Pathophysiology

1.) What is the most likely cause for this patients hypocalcemia? Explain your
answer.
Based on the information given in the case study, the patient demonstrates complications
often associated with Crohns disease and having multiple bowel resections. Selby (2000) states,
Crohns disease is characterized by transmural inflammation with deep ulceration, thickening of
the bowel wall and fistula formation(Selby, 2004, p.500).The most likely cause for this patients
hypocalcemia includes the inability to absorb and synthesize daily intake of nutrients obtained
from her diet due to resection of the ileum where most nutrients are absorbed. Calcium,
magnesium and iron as well as folic acid are predominately absorbed by the duodenum and
deficiencies are a typical consequence of expanded proximal small bowel resection.
Malabsorption of calcium may be particularly severe because absorption is further hampered by
binding of calcium to malabsorbed fatty acids and by vitamin D deficiency (Keller, Panter, &
Layer, 2004, p.980).
The patients labs demonstrate a deficiency in her calcium level with a value of 5.1,
magnesium level of 1.5 which indicates hypomagnesemia, phosphorus level of 2.3 which
indicates hypophosphatemia. McCance, Huether, Brashers, and Rote (2010) stated, there also
may be deficiencies in folic acid, Vitamin D absorption and calcium leading to bone disease (
McCance, Huether, Brashers, & Rote, 2010, p.1473). In addition to the abnormal lab values are
the musculoskeletal symptoms such as tenderness over ribs and severe pain on movement of
right hip with decreased range of motion. Osteomalacia is described as an inadequate amount of
calcium and phosphorus in the blood for mineralization of the bones. Based on the case study,

CASE STUDY 1

the patient was bedridden for two weeks; no exposure to sunlight and the inability to synthesize
Vitamin D can cause vitamin D deficiency which leads to bone diseases.
Tajika et al. (2004) states, the main function of Vitamin D is to preserve calcium and
phosphorus homeostasis by increasing the efficiency of intestinal calcium and phosphorus
absorption to maintain signal transduction, metabolic activities, neuromuscular function, and
promote skeletal mineralization. Vitamin D deficiency may contribute to the development of
metabolic bone diseases such as osteoporosis or osteomalacia (Tajika et al, 2004, p.527). The
patient is currently taking a multivitamin and calcium 500mg/day, but her intestinal tract is
unable to absorb dietary supplements taken by mouth or pill form. The Short Bowel Syndrome
(SBS) is a global malabsorption syndrome due to insufficient absorptive capacity and/or
disturbed gastrointestinal regulation resulting from extensive small bowel resections (Keller,
Panter, & Layer, 2004, p.978).
In order for this patient to effectively receive daily supplements, the patient would have
to receive parenteral supplementation. Enteral feeding should be encouraged unless this leads to
unmanageable fistula outputs. A home parenteral nutrition (HPN) service should be available to
the patient (Peck, Soo, Boland, Windsor, and Engledow, 2012, p.2).
2.) Which of the following statements regarding laboratory tests in metabolic bone
disease is false? Explain your answer.
a.) serum calcium is typically normal in patients with osteoporosis. True. The
population of individuals with osteoporosis is usually older with decreased bone density. A
normal bone density achieved in childhood will lead to mild osteoporosis at old age if calcium
intake is adequate throughout lifetime (Cirdeiu and Anton-Paduraru, 2013, p.116). It is

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important for older individuals to consume the daily recommended amount of calcium to prevent
the possibility of fractures from falls and osteoporosis.
b.) alkaline phosphatase is typically elevated in osteoporosis. False. Osteoporosis is a
common disease among older individuals. Menkes (2013) states, osteoporosis is characterized
by normal serum levels of calcium, phosphate, and alkaline phosphatase (Menke, 2013, p.9).
c.) serum phosphorus is typically normal in patients with Paget disease. True. The
breakdown and buildup of bone is essential in regulating the levels of calcium and phosphorus in
the blood. In most people with Paget disease, these levels remain normal. Certain conditions can
cause the balance to be disrupted, such as inactivity or the presence of a second disorder such as
hyperparathyroidism (Seton, 2012, p.1).
d.) patients with hyperparathyroidism often develop hypercalcemia. True. Primary
hyperparathyroidism and malignancy account for around 90% of cases of hypercalcemia.
Maintenance of normal calcium levels is under tight regulation by parathyroid hormone (PTH)
and vitamin D( Crowley & Gittoes, 2013, p.287).
3.) For each of the following metabolic bone diseases listed below, give a brief
definition of the disease, and briefly discuss what laboratory values that are helpful to
diagnose the disease. In addition, complete the following chart using arrows to denote
increased, decreased, or within normal range.
Osteomalacia is a bone disorder characterized by demineralization of the bone.
Individuals who suffer from primary conditions such as malabsorption syndrome can develop
secondary osteomalacia due to abnormalities in absorbing nutrients need to maintain bone health
and growth. Goula, Vervveridis, and Drosos (2012) stated, osteomalacia arises from a disorder
in the physiological process of bone turnover where the mineralization phase of bone remodeling

CASE STUDY 1

is impaired. Whenever Vitamin D deficiency is implicated in the etiology of osteomalacia, there

is evidence of secondary hyperparathyroidism ( Goula, Ververidis, & Drosos, 2012, p.2).
Laboratory values helpful in diagnosing the disease include serum calcium, serum phosphorus,
alkaline phosphatase, PTH, 25-hydroxyvitamin D, electrolytes, BUN and creatinine. Menkes
(2013) states, in nutritional osteomalacia, 25-hydroxyvitamin D is typically low, calcium and
phosphate low to low-normal, and parathyroid hormone and alkaline phosphatase high (p.3).
Osteoporosis is a common bone disease characterized by bone fragility and decreased
bone mass. It is most common amongst postmenopausal men and women and found secondary to
several illnesses such as nutritional conditions and endocrine diseases, and medications such as
corticosteroids. Menkes (2013) stated, Osteoporosis is characterized by normal serum levels of
calcium, phosphate, alkaline phosphatase (Menkes, 2013, p.9). Lab values that are helpful in
diagnosing secondary osteoporosis include complete blood count, complete metabolic panel
including creatinine, calcium, phosphorus, alkaline phosphatase, liver function test, twenty-four
hour urine calcium, sodium, and creatinine to check for calcium malabsorption or hypercalciuria,
testosterone levels in men and 25-hydroxyvitamin D level ( Diab & Watts, 2013, p.5).
Paget disease is a common bone disease characterized by aging skeleton and bone
enlargement. Seton (2013) states, it is the second most common disease of bone in the elderly
after osteoporosis, and the loss of structural integrity in affected bone conveys a risk of
fracture(Seton, 2013, p.452). Laboratory values helpful in diagnosing Paget disease include the
serum alkaline phosphatase which is usually elevated; serum calcium and phosphorus are normal
in most patients. Seton (2013) states, the serum alkaline phophatase (sAP), like the bonespecific alkaline phosphatase (bAP), is usually elevated in patients with Paget disease of the
bone (PDB) (Seton, 2013, p.6).

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Hyperparathyroidism is a condition in which the parathyroid glands release too much

parathyroid hormone caused by a tumor or certain illnesses. If there is too much parathyroid
hormone in the blood, calcium is released into the blood from the bones making the bones at risk
for weakness. Gasser (2013) states, Primary hyperparathyroidism (PHPT) is characterized by an
increased secretion of parathyroid hormone (PTH) together with hypercalcemia caused by the
increase of functional parathyroid tissue due to tumor or hyperplasia (Gasser, 2013, p.9).
Laboratory values helpful in diagnosing hyperparathyroidism include serum calcium,
ionized calcium, and PTH. Fuleihan and Silverberg (2013) states, the diagnosis of primary
hyperparathyroidism is usually made by finding a frankly elevated PTH concentration or one
that is within the normal range but inappropriately elevated given the patients hypercalcemia
(Fuleihan &Silverberg, 2013, p.1).
Disease

Serum Calcium

Serum Phosphorus

Alkaline
Phosphatase

Osteomalacia

Paget Disease

Hyperparathyroidism

4.) What is the most likely mechanism of osteomalacia in this patient? Explain your
answer.
In reviewing the case study, the most likely mechanism of osteomalacia involving this
patient may be due to nutritional deficiencies and the inability to absorb nutrients due to Crohns
disease. Menkes (2013) stated, osteomalacia should be suspected in cases of bone pain

CASE STUDY 1

associated with malabsorption, gastric bypass surgery, celiac sprue, chronic hepatic disease, and
chronic kidney disease (Menke, 2013, p.9). Due to the cobblestone formation within the
intestinal tract, the mucosa is unable to absorb calcium or Vitamin D, which is needed to regulate
calcium and phosphorus. The lab values demonstrated in the case clearly demonstrate values
indicated in osteomalacia such as decreased calcium, decreased phosphorus, and an increased
alkaline phosphatase. The patient also demonstrates the signs and symptoms associated with
osteomalacia such as bone pain and tenderness.