Answers

1. D. There is no evidence that affinity for D3 with its receptor is altered during aging. Aging is associated with vitamin D deficiency for several reasons. It is important for the elderly to receive vitamin D supplementation to prevent osteoporosis and the other problems associated with hypocalcemia. If they have chronic liver or renal conditions, use of one of the specific metabolites should be used, such as cal-citriol.

2. E. There is no good evidence that moderate amounts of alcohol contribute to osteoporosis. All of the other listed conditions can contribute to osteoporosis. Antiseizure medications interfere with activation of vitamin D; glucocorticoids stimulate bone resorption of calcium; renal loss of calcium can result in secondary hyperparathyroidism; and organ transplantation is associated with osteoporosis because of the glucocorticoids and other im-munosuppressive medications used. Individuals chronically taking these medications should take a bisphosphonate for prophylaxis. In patients prone to form kidney stones, a low dose of a thiazide diuretic will often block the renal loss of calcium and prevent osteoporosis and further stone formation.

3. A. Paget's disease is often asymptomatic and picked up on plain bone films. Patients with Paget's disease should have their serum calcium level determined to make sure that they are not hypercalcemic from excessive bone resorption, their serum alkaline phosphatase measured as a marker of new bone formation, a bone scan to determine whether other bones are involved, and a 24-hour urinary hy-droxyproline measurement to assess bone resorption. The patient who has minimal involvement and is biochemically normal does not need pharmacological therapy. No studies indicate that early treatment slows progression in individuals with the more severe form of this disorder.

4. A. Although all of the conditions can present as an asymptomatic nodule in the thyroid, the marked hy-percalcemia in this patient makes hyperparathy-roidism the probable diagnosis. Carcinomas of the thyroid are common, and outcomes are improved with early diagnosis. Medullary carcinoma and hy-perparathyroidism caused by hyperplasia may be inherited and are associated with the multiple endocrine neoplasia syndromes.

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