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Endocrine
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Hypercalcemia Workup
Flowchart
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PTH splits PTH-dependent vs PTH-independent.
Decision
Outcome
Decision
Elevated Ca. First step?
✓
Confirm with repeat + correct for albumin (or ionized Ca)
✗
Start IV bisphosphonate immediately
Decision
Confirmed — branching test?
✓
PTH
✗
Vitamin D first
Decision
PTH result?
✓
High-normal / elevated → PTH-dependent
✓
Suppressed → PTH-independent
Outcome
Primary or tertiary hyperparathyroidism, FHH, lithium
FHH: urine Ca/Cr clearance ratio <0.01.
Decision
PTH-independent — next labs?
✓
PTHrP, 25-OH vit D, 1,25-(OH)₂ vit D
Outcome
Malignancy (↑PTHrP), vit D toxicity, granulomatous disease, thiazides, milk-alkali, hyperthyroidism, vit A, immobilization
Severe symptomatic hypercalcemia (Ca >14 or symptoms): IV fluids → calcitonin (rapid) → bisphosphonate or denosumab (durable).