Clinical Problem-Solving: Stopping Short of Certainty

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Abstract
In the Clinical Problem-Solving exercise on hypercalcemia (July 7 issue),1 I disagree with Dr. Kreisberg's comment, made more than once, that the diagnosis of primary hyperparathyroidism can be ruled out at an early stage. I submit that this is not the case at all. It is important in any differential diagnosis to bear in mind at the outset that common disorders occur commonly, and the initial diagnostic approach should be based on this principle. The clinical history recounted in the first paragraph is extremely suggestive of primary hyperparathyroidism; in contrast, steroid-responsive vitamin D-mediated hypercalcemia is extremely uncommon.