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May 28, 1982

Differential Diagnosis of Hypercalcemia-Reply

JAMA. 1982;247(20):2780. doi:10.1001/jama.1982.03320450018016

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In Reply.—  Mr Bertini suggests that asking the question about a history of taking drugs that can cause hypercalcemia much earlier than decision 4 would save the patient "the pain and risks of multiple venipunctures and the costs of the concomitant laboratory tests." Let us consider how the algorithm might be applied to a patient with drug-induced hypercalcemia. Decision 1 asks for two tests, a serum calcium value and a serum protein electrophoresis, to avoid investigation of spurious hypercalcemia. Decision 2 asks whether there is a present or past history of carcinoma. Decision 3 asks whether hypercalcemia has been documented for more than one year in the patient's medical record and whether there are symptoms compatible with primary hyperparathyroidism, such as kidney stones or peptic ulcer. For drug-induced hypercalcemia, the questions in decisions 2 and 3 would most likely be answered negatively simply on the basis of only the history