The finding of hypercalcemia on routine biochemical testing or in the evaluation of postmenopausal women with osteoporosis is typically the initial clue to the diagnosis of primary hyperparathyroidism. The total serum calcium level, which combines both the free and albumin-bound components of circulating calcium, should be adjusted for the level of albumin. Measurement of ionized calcium may be useful in selected cases, such as in patients with hyperalbuminemia, thrombocytosis, Waldenström’s macroglobulinemia, and myeloma; these patients may have elevated levels of total serum calcium, but normal levels of ionized serum calcium (artifactual hypercalcemia).
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