Presentations
- Abdominal pain
- Altered cognition
- Asymptomatic with incidental findings
- Bone pain
- Cardiac arrythmias
- Constipation
- CKD-MBD
- Fractures
- Nausea or vomiting
- Numbness of hands, feet, mouth
- Preventative in hormone deprivation therapy for breast or prostate cancer
- Renal stones
- Tetany and/or cramping
Conditions
- Hormone deprivation therapy for breast or prostate cancer
- Hyperparathyroidism:
- medication-induced
- normocalcaemic
- primary
- secondary
- tertiary
- Hypocalcaemia:
- hypoparathyroidism:
- congenital
- idiopathic
- infiltrative
- post-surgical
- vitamin D deficiency
- Hypophosphatasia
- Pseudohypoparathyroidism:
- autosomal dominant hypocalcaemia (calcium -sensing receptor mutations)
- medication-induced
- vitamin D receptor mutations
- PTH-independent hypercalcaemia:
- malignancy-associated
- milk-alkali syndrome
- sarcoidosis
- Osteomalacia
- Osteopenia
- Osteoporosis
- Paget’s disease
- Vitamin D deficiency
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Presentations
- First presentation of hypercalcaemia in pregnancy
Conditions
- Complications of osteoporosis therapies, atypical femur fractures and medication-related osteonecrosis of the jaw
-
Disorder of high bone mass:
-
Hyperparathyroidism due to underlying genetic disorder:
- familial hypocalciuric hypercalcaemia
- familial isolated idiopathic hyperparathyroidism
- hyperparathyroidism-jaw tumour syndrome
- MEN1
- MEN2A
-
Hypophosphataemia:
- acquired
- inherited, including x-linked
-
Inherited disorders of skeletal dysplasia:
- fibrous dysplasia
- hyperostosis
- osteogenesis imperfecta
- Parathyroid cancer
- Pregnancy-related conditions including transient osteoporosis of the hip and lactation-related osteoporosis
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Inherited disorders/Disorders with a genetic basis
- Incidence and prevalence of conditions in Australian population
- Recognise and screen for the possibility of known genetic variants causing pathology
- Referral for genetic counselling, wherever needed
- Screening for associated pathology in known inherited disorders
- Screening of family members, when indicated
Osteoporosis screening
- Counsel patients with up-to-date best practice guidelines for nutritional lifestyle and exercise recommendations
- Identify risk factors for poor bone health
- Perform a fracture risk assessment using a validated fracture risk calculator (e.g. FRAX or Garvan tool)
- Population-based screening
- Provision of preventative care against osteoporosis
- Screening for secondary osteoporosis, such as:
- glucocorticoid treatment, Cushing syndrome
- hypogonadism, androgen deprivation
- malabsorption
- premature menopause
- systemic mastocytosis
Therapeutics
- Appropriate prescribing of nutritional therapy and physical activity
- Prescribe anti-resorptive and anabolic bone medications according to best practice, employing an individualised approach
- Hyperparathyroidism management with medical therapies
- Emergent management of severe or symptomatic hypercalcaemia
- Emergent management of severe or symptomatic hypocalcaemia:
- assessment and management of concomitant magnesium deficiency
- understand and interpret severity, including monitoring ECG changes
- Prescribing for rickets and osteomalacia
- Take preventative action to avoid or mitigate risk of adverse events from available pharmaceutical agents
Clinical assessment
- Assessment of nutrition and physical activity, screening for restrictive eating and overexercise, identifying and modifying risk factors for falls (where appropriate)
- FRAX
- Identify and refer patients for surgery where appropriate:
- triage patients with indications for surgical intervention according to condition severity
- Monitoring disease activity
- Monitoring response to therapy
- Provide perioperative care:
- long term management of post-surgical hypoparathyroidism and serum calcium management with calcitriol (to avoid nephrocalcinosis/hypercalciuria)
- patients undergoing parathyroid surgery
- patients with hypocalcaemia
- Review medications (including over-the-counter and non-prescription agents) for drug-drug and drug-disease interactions
Imaging
- Bone mineral density (and its limitations)
- Bone scintigraphy
- Localisation of parathyroid adenoma/cancer:
- 4D CT
- neck U/S
- nuclear medicine parathyroid scan
- Plain radiographs (e.g. identify and quantify vertebral fractures on thoracolumbar spine radiographs)
- Trabecular bone score, vertebral fracture assessment
Laboratory tests
- 1,25-dihydroxyvitamin D
- 24-hour or spot fasting urine collections for calcium, creatinine, and phosphate, with calculation of TmP/GFR and calcium/creatinine ratio
- 25-hydroxyvitamin D
- Bone-specific ALP
- Bone turnover markers
- Calcium (corrected and ionised)
- Electrolytes
- FGF-23
- iPTH, PTHrp
- Kidney function
- LFT
- Magnesium
- Phosphate
- Screening for:
- nutritional deficits, including:
- albumin
- electrolytes
- serum protein
- secondary causes of osteoporosis, including:
- coeliac disease
- hypogonadism
- multiple myeloma
- TFTs
- vitamin D deficiency
- Tmp/GFR
Evidence-based practice
- Remain abreast of evidence for best practice and apply this using clinical judgement and individual circumstances in partnership with patients
Management considerations
- Conception counselling
- Conservative management where able and individualised care
- Genetic counselling
- Incorporate environmentally sustainable practices in clinical care
- Pregnancy management:
- first presentation of hypercalcaemia in pregnancy
- pre-existing hyperparathyroidism
- pre-existing hypocalcaemia
- pre-existing osteoporosis, including discussion of the duration of lactation
- Osteoporosis considerations:
- intermittent secondary amenorrhoea
- malabsorption and lactose intolerance symptoms
- over exercise
- restrictive eating, including meat/protein and dairy avoidance
- underweight
