symptom.hypercalcemia-workup.v1

Hypercalcemia evaluation

symptomacutechronicundifferentiatedadultgeriatricoutpatientacute

Start encounter →Print handoutPRODUCTION

Phase C shard-3-neuro-sym wave-14 (2026-05-14) — symptom-workup template clones from symptom.hyperkalemia-workup.v1, symptom.fuo.v1, symptom.anemia-workup.v1. Engine scope: hypercalcemia (Ca >10.5) evaluation — severity-stratified (mild <12, moderate 12-14, severe >14) + cause stratification (PTH-dependent vs PTH-independent) + dispositional routing to disease-specific engines. Phenotypes covered (≥8): severe_Ca_gt_14_with_AMS_ECG_changes, moderate_Ca_12_to_14_symptomatic, mild_Ca_lt_12_asymp, primary_hyperparathyroidism (~80% ambulatory), malignancy_hypercalcemia_LOH (PTHrP humoral / lytic / 1,25-D — ~50% inpatient), granulomatous_sarcoid_TB, thiazide_lithium_induced, familial_hypocalciuric_hypercalcemia_FHH, immobilization, milk_alkali, vitamin_D_toxicity, vitamin_A_toxicity, pheochromocytoma_associated (MEN-2), renal_transplant_tertiary_hyperPTH, multiple_myeloma_CRAB. Bayesian linkage (LR+, LR−, pre-test priors by Ca level + PTH-dependent vs independent, T_treat thresholds) lives in companion depth bundle _briefs/symptom.hypercalcemia-workup.v1.depth.md. 4 sibling differentiation rows: endo.hyperparathyroidism.v1 + endo.pheochromocytoma.v1 + heme.multiple-myeloma.chronic.v1 + syndrome.hyperkalemia.core.v1 (peer electrolyte syndrome — all confirmed in ALL_DOSSIERS). 10 severity_triggers: severe_Ca_gt_14_or_symptomatic, primary_hyperparathyroidism_dx, malignancy_hypercalcemia_PTHrP, multiple_myeloma_CRAB, granulomatous_sarcoid_TB, FHH, thiazide_lithium_induced, pheochromocytoma_MEN2, vitamin_D_toxicity, tertiary_hyperPTH_post_transplant. KEY SAFETY RULES: PTH FIRST diagnostic step; AVOID LR fluids (contains Ca); AVOID thiazide + Ca + vit D supplements during workup; AVOID furosemide before volume repletion; denosumab if AKI / bisphosphonate CI; HD if severe + refractory + AKI; α-block before β-block in pheochromocytoma surgery prep; FHH → AVOID parathyroidectomy (does not resolve). Calculators wired (0): schema-blocked — calc.corrected_ca_albumin, calc.ionized_ca_adjustment. Ticketed in shard-3 state file. Panels wired: panel.cbc + panel.renal + panel.lft + panel.inflammation + panel.thyroid. Schema-blocked: workup.hypercalcemia_panel — NOT in clinical-tools-registry; manual application in setting playbook required_assessments. Regimen_axes intentionally empty — engine is triage + acute management at this layer. Stepwise pharmacologic + cause-directed ladder lives in setting_playbooks.ed.drug_actions + setting_playbooks.outpatient.drug_actions. Setting playbooks: ed (severe) + outpatient (mild) — split per severity-stratified template like syndrome.hyperkalemia.core.v1. SCAFFOLDED status: no workup.hypercalcemia_panel in clinical-tools-registry; PRODUCTION audit would fail. Will promote once registry entries land.

Entry points (16)

lab_abnormality
Severe hypercalcemia — Ca >14 mg/dL + altered mental status + ECG changes (short QT, T-wave changes, AF, bradyarrhythmia) — STAT IV NS (200-300 mL/h) + calcitonin 4 IU/kg SC/IM q12h + bisphosphonate (zoledronate 4 mg IV OR pamidronate 60-90 mg IV) OR denosumab 60-120 mg SC if AKI; hemodialysis if severe refractory + AKI
severe_ca_gt_14_with_ams_ecg_changes
lab_abnormality
Moderate hypercalcemia — Ca 12-14 mg/dL + symptoms (nausea, polyuria, confusion, weakness, constipation, bone pain) — IVF NS + bisphosphonate (zoledronate 4 mg IV) ± calcitonin if rapid normalization needed; workup cause
moderate_ca_12_to_14_symptomatic
lab_abnormality
Mild hypercalcemia — Ca <12 mg/dL + asymptomatic — outpatient workup; PTH first (PTH-dependent vs independent); CRAB criteria screen for myeloma; thiazide / lithium review
mild_ca_lt_12_asymptomatic
lab_abnormality
Hypercalcemia + elevated PTH + low/normal urinary Ca:Cr ratio + osteoporosis — primary hyperparathyroidism (most common ambulatory cause, ~80%); route endo.hyperparathyroidism.v1; sestamibi scan + parathyroidectomy criteria (Ca >1 above ULN, eGFR <60, T-score <-2.5, age <50, kidney stones)
primary_hyperparathyroidism
lab_abnormality
Hypercalcemia + suppressed PTH + cancer history / risk OR no clear cause + B-symptoms + WL — malignancy hypercalcemia (~50% of inpatient hypercalcemia); 3 mechanisms: PTHrP (humoral — squamous cell, RCC, breast), lytic bone mets (~20%), 1,25-(OH)2-vit-D (lymphoma, granulomatous); workup PTHrP, 25-OH-D, 1,25-(OH)2-D, SPEP / UPEP / sFLC (myeloma)
malignancy_hypercalcemia_loh_pthrp_vit_d
lab_abnormality
Hypercalcemia + suppressed PTH + elevated 1,25-(OH)2-D + chronic cough / hilar adenopathy / endemic exposure — granulomatous (sarcoid, TB, histoplasmosis, GPA, beryllium) — 1α-hydroxylase activity in macrophages; route to ID / pulm; corticosteroids may be needed
granulomatous_sarcoid_tb_1_25_oh_d_high
lab_abnormality
Hypercalcemia + thiazide diuretic OR lithium use + mildly elevated PTH (unmasking) — thiazide / lithium-induced; deprescribe / switch; re-check Ca 4-6 wk after; unmasked underlying primary hyperPTH common
thiazide_lithium_induced
lab_abnormality
Hypercalcemia + family history + low urinary Ca:Cr ratio <0.01 — familial hypocalciuric hypercalcemia (FHH) — CASR mutation; AVOID parathyroidectomy (does not resolve); recognize to prevent unnecessary surgery
familial_hypocalciuric_hypercalcemia_fhh_low_urine_ca
lab_abnormality
Hypercalcemia + recent prolonged immobilization (especially adolescent, Paget disease, spinal cord injury) — immobilization-induced; bone resorption > formation; mobilize as soon as possible; bisphosphonate adjunct
immobilization_hypercalcemia
lab_abnormality
Hypercalcemia + chronic calcium carbonate use (heartburn) OR vitamin D excess + metabolic alkalosis + AKI — milk-alkali syndrome (now resurgent with antacid use); stop offending agent; IVF + bisphosphonate if severe
milk_alkali_calcium_carbonate_overuse
lab_abnormality
Hypercalcemia + suppressed PTH + elevated 25-OH-D (>150 ng/mL) — vitamin D toxicity; iatrogenic from supplementation; stop vit D + Ca; corticosteroids if severe; long half-life requires prolonged management
vitamin_d_toxicity_25_oh_d_high
lab_abnormality
Hypercalcemia + chronic vitamin A excess (retinoid use, supplements) — increased osteoclast activity; rare; stop vit A; IVF + bisphosphonate if severe
vitamin_a_toxicity_hypercalcemia
lab_abnormality
Hypercalcemia + episodic HTN + headache + diaphoresis + palpitations + elevated metanephrines — pheochromocytoma (MEN-2 syndrome — co-occurs with medullary thyroid + pheo); route endo.pheochromocytoma.v1; α-blockade before β-blockade before surgery
pheochromocytoma_associated
lab_abnormality
Hypercalcemia + persistent post-renal-transplant + elevated PTH — tertiary hyperparathyroidism; chronic CKD → autonomous PTH secretion; cinacalcet if Ca >10.2 + persistent ≥1 yr post-transplant; parathyroidectomy if severe
renal_transplant_post_op_persistent_hyper_pth
lab_abnormality
Hypercalcemia + CRAB criteria (hyperCa, renal, anemia, bone lesions) + monoclonal protein + bone pain — multiple myeloma; route heme.multiple-myeloma.chronic.v1; SPEP / UPEP / sFLC / serum free light chains
multiple_myeloma_crab
lab_abnormality
Severe hypercalcemia — Ca >14 mg/dL even WITHOUT symptoms — emergent workup + treatment due to high arrhythmia + AKI risk; ED for monitoring + IVF + bisphosphonate
severe_ca_gt_14_no_symptoms_emergent_workup

Required inputs (35)

agerequired
demographic • used at CONTEXT
Age shifts priors: <50 + asymptomatic hyperCa → consider FHH; ≥50 + de-novo hyperCa → primary hyperPTH most common; ≥60 + severe → malignancy more likely; AACE PMID 28079225 (verify) + NEJM 2017 PMID 28680000 (verify)
sexrequired
demographic • used at CONTEXT
Sex shifts priors: female > male for primary hyperPTH (3:1); post-menopausal predominant; certain cancers sex-specific (prostate vs breast / ovarian)
serum_calcium_totalrequired
lab • used at FRAME
Total Ca — confirm hypercalcemia (>10.5 mg/dL); correct for albumin (Corrected Ca = Total Ca + 0.8 × (4 − Albumin)); ionized Ca preferred when available, especially with abnormal protein / acid-base
serum_albumin_corrected_carequired
lab • used at FRAME
Albumin correction; if abnormal, ionized Ca more accurate; hypoalbuminemia → falsely low total Ca; multiple myeloma + paraproteinemia → false-positive total Ca
ionized_calcium_if_available
lab • used at FRAME
Ionized Ca — gold standard when total Ca uncertain (hypoalbuminemia, paraproteinemia, acid-base derangement); normal range 4.65-5.25 mg/dL or 1.15-1.31 mmol/L
symptoms_bones_stones_groans_moans_psychic_overtonesrequired
symptom • used at ENTRY
Classic presentation: bones (pain, fractures), stones (kidney stones), abdominal groans (nausea, constipation, peptic ulcer, pancreatitis), psychic moans (confusion, depression, fatigue, weakness); guides severity assessment + diagnosis
severity_red_flags_ams_arrhythmia_acute_akirequired
symptom • used at RED_FLAGS
Red flags: altered mental status / seizure / coma → severe; ECG changes (short QT, T-wave, AF, bradyarrhythmia); acute AKI; volume depletion with hypotension; severe Ca >14 even if asymptomatic → ED
sbprequired
vital • used at CONTEXT
Hypotension from volume depletion (polyuria, vomiting) → IVF emergent; tachycardia + dehydration; hypertensive episodic (pheochromocytoma)
hr_ecgrequired
vital • used at RED_FLAGS
Bradyarrhythmia + AF + short QT in severe; ECG essential; cardiac monitoring in severe hyperCa
medication_review_thiazide_lithium_vit_d_ca_vit_a_estrogenrequired
history • used at CONTEXT
Thiazide diuretic (unmask hyperPTH), lithium (alters Ca-sensing receptor), vitamin D supplementation, calcium carbonate (milk-alkali), vitamin A (retinoids), tamoxifen / aromatase inhibitors, theophylline, ganciclovir; deprescribe + reassess
malignancy_history_screening_statusrequired
history • used at CONTEXT
Known cancer + new hyperCa → likely paraneoplastic; cancer screening status by age + family hx; ~50% of inpatient hypercalcemia is malignancy-related
family_history_hyper_ca_men_syndromesrequired
history • used at CONTEXT
Family hx hyperCa → consider FHH (autosomal dominant, CASR mutation), MEN-1 (parathyroid + pancreatic + pituitary), MEN-2A (parathyroid + medullary thyroid + pheo), MEN-2B (medullary thyroid + pheo + mucosal neuromas)
sarcoid_tb_granulomatous_historyrequired
history • used at CONTEXT
Sarcoidosis, TB, histoplasmosis, GPA, berylliosis — granulomatous disease with 1α-hydroxylase activity → elevated 1,25-(OH)2-D; corticosteroids may be needed (PMID 21527617 — verify)
immobilization_recent_paget_spinal_cord
history • used at CONTEXT
Recent prolonged immobilization (especially adolescent, Paget disease, spinal cord injury) → bone resorption > formation
renal_transplant_status_chronic_ckd
history • used at CONTEXT
Post-renal-transplant + persistent hyperCa → tertiary hyperPTH; chronic CKD with progression → autonomous PTH; cinacalcet vs parathyroidectomy
pth_intact_diagnostic_firstrequired
lab • used at INITIAL_WORKUP
PTH (intact assay) — FIRST diagnostic step after hypercalcemia confirmed; HIGH/normal-high → PTH-dependent (primary hyperPTH, lithium, FHH, MEN, tertiary); LOW/suppressed → PTH-independent (malignancy, granulomatous, vit D toxicity, milk-alkali, hyperthyroid, immobilization)
phosphorus_serumrequired
lab • used at INITIAL_WORKUP
PO4 — low in primary hyperPTH (PTH wastes PO4); high in vitamin D toxicity, milk-alkali; provides clinical context
creatinine_bun_egfrrequired
lab • used at INITIAL_WORKUP
Cr + eGFR — AKI common with severe hyperCa (volume depletion + Ca nephrocalcinosis); long-term: CKD progression in primary hyperPTH
25_oh_vitamin_drequired
lab • used at INITIAL_WORKUP
25-OH-D — vitamin D toxicity (>150 ng/mL is toxic); deficiency in primary hyperPTH common; replacement complicated
1_25_oh_vitamin_d_if_granulomatous_suspected
lab • used at BRANCHING_WORKUP
1,25-(OH)2-D — elevated in granulomatous disease (extra-renal 1α-hydroxylase); lymphoma; primary hyperPTH (also elevated)
pthrp_if_suspected_malignancy
lab • used at BRANCHING_WORKUP
PTHrP — elevated in humoral hypercalcemia of malignancy (HHM) — squamous cell, RCC, breast, ovarian; ~80% of malignancy hypercalcemia has elevated PTHrP (PMID 26261118 — verify)
urinary_ca_24h_creatinine_ratio
lab • used at BRANCHING_WORKUP
24-h urinary Ca + Ca:Cr ratio — LOW (<0.01) → FHH (do not refer for parathyroidectomy); NORMAL/HIGH → primary hyperPTH; HIGH → vit D toxicity / milk-alkali
cbc_with_diffrequired
lab • used at INITIAL_WORKUP
Anemia (myeloma — CRAB), pancytopenia (marrow infiltration), elevated WBC (infection / inflammation)
lft_alk_phos_bone_specificrequired
lab • used at INITIAL_WORKUP
Alkaline phosphatase — elevated in Paget disease, bone mets, primary hyperPTH (high turnover); LFT for hepatic mets / paraneoplastic
spep_upep_sflc_if_age_50_or_anemia
lab • used at BRANCHING_WORKUP
SPEP / UPEP / sFLC — multiple myeloma (CRAB: hyperCa, renal, anemia, bone lesions); age ≥50 + anemia + hyperCa → routine screen; route heme.multiple-myeloma.chronic.v1
tsh_free_t4_if_hyperthyroid_suspected
lab • used at BRANCHING_WORKUP
TSH — hyperthyroidism is rare cause of hyperCa (increased bone turnover); useful in unexplained cases
metanephrines_if_pheo_suspected_men_syndrome
lab • used at BRANCHING_WORKUP
Plasma fractionated metanephrines or 24-h urinary metanephrines — pheochromocytoma; MEN-2 syndrome screen (hyperCa + medullary thyroid + pheo); route endo.pheochromocytoma.v1
ace_level_lysozyme_sarcoid_screen
lab • used at BRANCHING_WORKUP
ACE level (sensitivity ~60%, not diagnostic alone), lysozyme — sarcoidosis adjunct; HRCT chest + biopsy diagnostic (PMID 21527617 — verify)
cxr_screen_malignancy_sarcoidrequired
imaging • used at INITIAL_WORKUP
CXR — lung mass (squamous → PTHrP), hilar adenopathy (sarcoid, lymphoma), TB, COPD
sestamibi_parathyroid_scan_if_pth_elevated
imaging • used at BRANCHING_WORKUP
Sestamibi parathyroid scan — localize adenoma in primary hyperPTH for surgical planning; combined with neck US; route endo.hyperparathyroidism.v1
ct_chest_abdomen_pelvis_if_malignancy_suspected
imaging • used at BRANCHING_WORKUP
CT C/A/P — occult malignancy (lung, breast, RCC, GI, ovarian, lymphoma); especially if PTH suppressed + B-symptoms + WL
skeletal_survey_or_pet_ct_myeloma_workup
imaging • used at BRANCHING_WORKUP
Skeletal survey or PET-CT — lytic bone lesions (myeloma, mets); MRI spine if cord-compression concern
dexa_scan_osteoporosis_screen
imaging • used at BRANCHING_WORKUP
DEXA — osteoporosis (T-score <-2.5) is parathyroidectomy criterion in primary hyperPTH; high turnover from chronic hyperCa
renal_ultrasound_nephrocalcinosis_stones
imaging • used at BRANCHING_WORKUP
Renal US — nephrolithiasis + nephrocalcinosis from chronic hyperCa; primary hyperPTH parathyroidectomy criterion
ecg_for_qt_arrhythmiarequired
imaging • used at INITIAL_WORKUP
ECG — short QT, T-wave changes, AF, bradyarrhythmia in severe; baseline + serial in ED / inpatient

12-phase flow (12)

1FRAME
Confirm hypercalcemia: Ca >10.5 mg/dL (corrected for albumin) OR ionized Ca >1.31 mmol/L; severity stratification (mild <12, moderate 12-14, severe >14 OR symptomatic regardless of level); rule out pseudohypercalcemia (paraproteinemia, falsely elevated)
inputs: serum_calcium_total, serum_albumin_corrected_ca, ionized_calcium_if_available
advance: Hypercalcemia confirmed + severity classified
2ENTRY
Symptoms — bones (pain, fractures), stones (kidney stones), abdominal groans (nausea, constipation, peptic ulcer, pancreatitis), psychic moans (confusion, depression, fatigue, weakness, AMS, coma); ECG changes; AKI; volume depletion
inputs: symptoms_bones_stones_groans_moans_psychic_overtones
advance: Symptom complex characterized
3CONTEXT
Age + sex + medication review (thiazide, lithium, vit D, Ca carbonate, vit A, tamoxifen, theophylline) + malignancy history + family hx hyperCa / MEN syndromes + granulomatous disease history (sarcoid, TB) + immobilization + renal transplant status
inputs: age, sex, sbp, hr_ecg, medication_review_thiazide_lithium_vit_d_ca_vit_a_estrogen, malignancy_history_screening_status, family_history_hyper_ca_men_syndromes, sarcoid_tb_granulomatous_history, immobilization_recent_paget_spinal_cord, renal_transplant_status_chronic_ckd
advance: Context comprehensive
4RED_FLAGS
Severe Ca >14 (regardless of symptoms) → ED + cardiac monitoring + emergent IVF + calcitonin + bisphosphonate; Ca 12-14 with symptoms (AMS, ECG changes, AKI) → ED; Ca >14 with refractory features + AKI → hemodialysis consideration; severe vol depletion / hypotension → IVF + cardiac monitoring
inputs: severity_red_flags_ams_arrhythmia_acute_aki
advance: Severity-stratified disposition documented
5INITIAL_WORKUP
Confirm + classify: PTH (intact assay — FIRST diagnostic step); BMP + Ca + Mg + PO4 (electrolytes); albumin (Ca correction); 25-OH-D; Cr + eGFR; CBC + diff; LFT + alk phos; UA; ECG (severity); CXR (malignancy / sarcoid screen)
inputs: pth_intact_diagnostic_first, phosphorus_serum, creatinine_bun_egfr, 25_oh_vitamin_d, cbc_with_diff, lft_alk_phos_bone_specific, ecg_for_qt_arrhythmia, cxr_screen_malignancy_sarcoid
actions: panel.cbc, panel.renal, panel.lft, panel.inflammation
advance: Tier 1 returned + PTH-dependent vs independent classified
6BRANCHING_WORKUP
PTH-DEPENDENT (elevated PTH): primary hyperPTH → sestamibi scan + neck US → route endo.hyperparathyroidism.v1; tertiary hyperPTH (post-transplant) → cinacalcet vs parathyroidectomy; lithium-induced → deprescribe + reassess; FHH → 24-h urinary Ca:Cr ratio low + family hx → CASR genetic testing → AVOID parathyroidectomy. PTH-INDEPENDENT (suppressed PTH): malignancy → PTHrP + CT C/A/P + skeletal survey + SPEP/UPEP/sFLC (myeloma — route heme.multiple-myeloma.chronic.v1); granulomatous → 1,25-(OH)2-D + ACE + HRCT chest + biopsy; vitamin D toxicity → 25-OH-D >150; milk-alkali → calcium carbonate hx + alkalosis; hyperthyroid → TSH; immobilization → mobilization; pheochromocytoma → metanephrines + MEN-2 screen → route endo.pheochromocytoma.v1.
inputs: 1_25_oh_vitamin_d_if_granulomatous_suspected, pthrp_if_suspected_malignancy, urinary_ca_24h_creatinine_ratio, spep_upep_sflc_if_age_50_or_anemia, tsh_free_t4_if_hyperthyroid_suspected, metanephrines_if_pheo_suspected_men_syndrome, ace_level_lysozyme_sarcoid_screen, sestamibi_parathyroid_scan_if_pth_elevated, ct_chest_abdomen_pelvis_if_malignancy_suspected, skeletal_survey_or_pet_ct_myeloma_workup, dexa_scan_osteoporosis_screen, renal_ultrasound_nephrocalcinosis_stones
advance: Cause identified or routed to specific engine
7DIFFERENTIAL
PTH-DEPENDENT (~85% of ambulatory): Primary hyperparathyroidism (~80% ambulatory — adenoma 85%, hyperplasia 15%, carcinoma <1%); Tertiary hyperPTH (post-transplant CKD); Lithium-induced; Familial hypocalciuric hypercalcemia (FHH — CASR mutation); MEN-1, MEN-2A syndromes. PTH-INDEPENDENT (~50% inpatient — most severe): Malignancy (3 mechanisms: PTHrP humoral / lytic bone mets / 1,25-D lymphoma; squamous, RCC, breast, ovarian — PMID 28110218); Granulomatous (sarcoid, TB, histoplasmosis, GPA, berylliosis — PMID 21527617); Vitamin D toxicity (>150 ng/mL 25-OH-D); Vitamin A toxicity; Milk-alkali (Ca carbonate); Hyperthyroidism; Immobilization (Paget, spinal cord injury, adolescent); Pheochromocytoma (MEN-2); Multiple myeloma (CRAB — heme.multiple-myeloma.chronic.v1).
advance: Differential ranked by PTH-dependent vs independent
8RISK_STRATIFICATION
Severity by Ca level (mild <12, moderate 12-14, severe >14); symptomatic (AMS, ECG changes, AKI, volume depletion); acute vs chronic (acute → severe symptoms at lower Ca); cause-specific (malignancy worse prognosis); parathyroidectomy criteria (Ca >1 above ULN, eGFR <60, DEXA T-score <-2.5, age <50, kidney stones — endo.hyperparathyroidism.v1)
advance: Risk-stratified treatment plan
9TREATMENT
Severe (>14 or symptomatic): IVF NS 200-300 mL/h (avoid LR — contains Ca; correct vol depletion); calcitonin 4 IU/kg SC/IM q12h (fast onset 4-6 h, tachyphylaxis 48-72 h); bisphosphonate IV — zoledronate 4 mg over 15 min OR pamidronate 60-90 mg over 4-24 h (onset 24-48 h, peak 4-7 d); denosumab 60-120 mg SC q4w if AKI / refractory / bisphosphonate failure (PMID 30231007 — verify); hemodialysis if severe + AKI / refractory / heart failure precluding fluid load; corticosteroids (prednisone 40-60 mg/d) for granulomatous, vitamin D toxicity, lymphoma. Moderate (12-14 symptomatic): IVF + bisphosphonate. Mild (<12 asymptomatic): outpatient workup + treat cause; AVOID thiazide + Ca + vit D supplements. Cause-directed: parathyroidectomy (primary hyperPTH — endo.hyperparathyroidism.v1); cinacalcet (CaSR allosteric activator — primary hyperPTH if surgery contraindicated, parathyroid carcinoma, tertiary post-transplant); deprescribe thiazide / lithium / vit D / Ca / vit A; treat malignancy; corticosteroids for granulomatous; mobilization for immobilization.
advance: Treatment plan initiated + cause-directed
10DISPOSITION
ED → ICU if severe (>14, AMS, ECG changes, AKI requiring HD); ED admit inpatient if moderate symptomatic; outpatient workup if mild + asymptomatic; specialty referral: endocrine (primary hyperPTH parathyroidectomy candidate); oncology (malignancy); nephrology (HD); pulm/ID (granulomatous); cardiology (arrhythmia); heme/onc (myeloma)
advance: Disposition assigned
11MONITORING
ICU: continuous cardiac monitoring, q1-2h Ca + electrolytes, hourly UOP; inpatient: q4-6h Ca, daily BMP, fluid balance; outpatient: q1-3 mo Ca + electrolytes; bisphosphonate response 24-72 h; calcitonin tachyphylaxis 48-72 h; parathyroidectomy follow-up (Ca + PTH q6mo first year); cinacalcet effect (Ca normalization 1-2 wk)
advance: Monitoring plan documented
12FOLLOWUP
Cause-specific follow-up: parathyroidectomy 6 wk + 6 mo (Ca + PTH); cinacalcet (Ca + PTH + electrolytes q3 mo); cancer surveillance; granulomatous (treat underlying); deprescribing review; lifestyle (hydration, AVOID Ca / vit D supplements unless replacement specifically needed)
advance: Long-term plan + follow-up scheduled