{"id":11050,"date":"2026-09-16T00:25:36","date_gmt":"2026-09-16T08:25:36","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=11050"},"modified":"2026-08-13T16:50:56","modified_gmt":"2026-08-14T00:50:56","slug":"pance-question-of-the-day-generalized-muscle-aching","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-generalized-muscle-aching","title":{"rendered":"PANCE\u00ae Question of the Day: Generalized muscle aching"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_86 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-generalized-muscle-aching\/#The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\" >The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-generalized-muscle-aching\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-generalized-muscle-aching\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-generalized-muscle-aching\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-generalized-muscle-aching\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-generalized-muscle-aching\/#References\" >References&nbsp;<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Prepare for the PANCE\u00ae with this emergency department scenario involving a<\/em><\/strong> <strong><em>patient experiencing generalized muscle aches, weakness and pain in the left hand. What&#8217;s the diagnosis? Let\u2019s find out!<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A <strong>74-year-old woman<\/strong> is brought to the emergency department because of <strong>generalized muscle aching, weakness<\/strong> and <strong>pain in the left hand<\/strong>. The symptoms started gradually a few months ago and have been progressing over time. Past medical history is notable for <strong>hypertension, type 2 diabetes mellitus, <\/strong>and <strong>end-stage renal disease on dialysis for 2 years<\/strong>. Her medications include amlodipine, hydralazine, and insulin glargine. A radiograph of the patient\u2019s hands is shown below:<\/p>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"610\" height=\"453\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_5eda65.png\" alt=\"\" class=\"wp-image-11053\" style=\"width:445px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_5eda65.png 610w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_5eda65.png?resize=300,223 300w\" sizes=\"auto, (max-width: 610px) 100vw, 610px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Routine blood work is performed. Which of the following sets of findings will <em>most likely<\/em> be seen in this patient?<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td>&nbsp;<\/td><td><strong>Parathyroid Hormone<\/strong>&nbsp;<\/td><td><strong>Serum Calcium<\/strong>&nbsp;<\/td><td><strong>Serum Phosphate<\/strong>&nbsp;<\/td><\/tr><tr><td><strong>A.\u00a0<\/strong><\/td><td>Increased&nbsp;<\/td><td>Increased&nbsp;<\/td><td>Increased&nbsp;<\/td><\/tr><tr><td><strong>B.\u00a0<\/strong><\/td><td>Increased&nbsp;<\/td><td>Increased&nbsp;<\/td><td>Decreased&nbsp;<\/td><\/tr><tr><td><strong>C.\u00a0<\/strong><\/td><td>Increased&nbsp;<\/td><td>Decreased&nbsp;<\/td><td>Increased&nbsp;<\/td><\/tr><tr><td><strong>D.\u00a0<\/strong><\/td><td>Increased&nbsp;<\/td><td>Decreased&nbsp;<\/td><td>Decreased&nbsp;<\/td><\/tr><tr><td><strong>E.\u00a0<\/strong><\/td><td>Decreased&nbsp;<\/td><td>Increased&nbsp;<\/td><td>Decreased&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down to find the answer!&nbsp;<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Learn with Osmosis\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/iDxHtjjCMbU?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td>&nbsp;<\/td><td><strong>Parathyroid Hormone<\/strong><strong><\/strong><\/td><td><strong>Serum Calcium<\/strong><strong><\/strong><\/td><td><strong>Serum Phosphate<\/strong><strong><\/strong><\/td><\/tr><tr><td><strong>C.&nbsp;<\/strong><\/td><td>Increased&nbsp;<\/td><td>Decreased&nbsp;<\/td><td>Increased&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Correct: <\/strong>See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td>&nbsp;<\/td><td><strong>Parathyroid Hormone<\/strong>&nbsp;<\/td><td><strong>Serum Calcium<\/strong>&nbsp;<\/td><td><strong>Serum Phosphate<\/strong>&nbsp;<\/td><\/tr><tr><td><strong>A.\u00a0<\/strong><\/td><td>Increased\u00a0<\/td><td>Increased&nbsp;<\/td><td>Increased&nbsp;<\/td><\/tr><tr><td colspan=\"4\"><strong>Incorrect:<\/strong>&nbsp;This pattern is seen in&nbsp;<strong>tertiary hyperparathyroidism<\/strong>, which is a state of excessive PTH secretion after&nbsp;a long period&nbsp;of secondary hyperthyroidism, reflecting the development of autonomous parathyroid gland function. It is preemptive to diagnose this patient as tertiary hyperparathyroidism without checking the response to therapy.&nbsp;<\/td><\/tr><tr><td><strong>B.\u00a0<\/strong><\/td><td>Increased&nbsp;<\/td><td>Increased&nbsp;<\/td><td>Decreased&nbsp;<\/td><\/tr><tr><td colspan=\"4\"><strong>Incorrect:<\/strong>&nbsp;This pattern is seen in<strong>&nbsp;primary hyperparathyroidism<\/strong>. In&nbsp;the majority of&nbsp;cases, primary hyperparathyroidism is caused by a benign adenoma of a single parathyroid gland that autonomously secretes PTH, resulting in elevated calcium and decreased phosphate levels. However, the patient\u2019s history of end-stage kidney disease provides a more likely explanation for her clinical and radiographic findings.&nbsp;<\/td><\/tr><tr><td><strong>D.\u00a0<\/strong><\/td><td>Increased&nbsp;<\/td><td>Decreased&nbsp;<\/td><td>Decreased&nbsp;<\/td><\/tr><tr><td colspan=\"4\"><strong>Incorrect:<\/strong>&nbsp;This pattern is seen in patients with&nbsp;<strong>vitamin D deficiency<\/strong>. Vitamin D is activated to calcitriol in the kidneys and markedly increases intestinal calcium and phosphate absorption. Lack of vitamin D causes a negative feedback response that increases PTH secretion from the parathyroid glands. However, the patient\u2019s history of end-stage kidney disease provides a more likely explanation for her clinical and radiographic findings.&nbsp;<\/td><\/tr><tr><td><strong>E.\u00a0<\/strong><\/td><td>Decreased&nbsp;<\/td><td>Increased&nbsp;<\/td><td>Decreased&nbsp;<\/td><\/tr><tr><td colspan=\"4\"><strong>Incorrect:<\/strong>&nbsp;Such&nbsp;set&nbsp;of findings can be seen in patients with&nbsp;<strong>humoral hypercalcemia of malignancy<\/strong>&nbsp;that is caused by secretion of parathyroid hormone-related peptide by malignant tumor cells. The rise in calcium and decline in phosphate levels cause negative feedback inhibition of endogenous PTH production, resulting in low PTH levels.&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-image alignleft size-full is-resized\"><img loading=\"lazy\" decoding=\"async\" width=\"936\" height=\"423\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_4fde1c.png\" alt=\"Osmosis.org style illustration of a hyperparathyroidism lab table comparing serum calcium, serum phosphate, and parathyroid hormone levels in primary, secondary, and tertiary hyperparathyroidism.\" class=\"wp-image-11054\" style=\"aspect-ratio:2.2128507777690927;width:482px;height:auto\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_4fde1c.png 936w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_4fde1c.png?resize=300,136 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/09\/image_4fde1c.png?resize=768,347 768w\" sizes=\"auto, (max-width: 936px) 100vw, 936px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">This patient with&nbsp;<strong>end-stage renal disease<\/strong>&nbsp;(ESRD) on&nbsp;<strong>hemodialysis&nbsp;<\/strong>has&nbsp;progressive bone&nbsp;<strong>pain<\/strong>, muscle&nbsp;<strong>weakness<\/strong>, and characteristic hand radiograph findings showing&nbsp;<strong>subperiosteal bone resorption<\/strong>&nbsp;and multiple lytic expansile lesions (i.e.&nbsp;<strong>brown tumors<\/strong>&nbsp;(arrows)), consistent with&nbsp;<strong>osteitis fibrosa cystica<\/strong>&nbsp;due to&nbsp;<strong>secondary hyperparathyroidism<\/strong>.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Secondary hyperparathyroidism<\/strong>&nbsp;commonly develops in patients with&nbsp;<strong>chronic kidney disease<\/strong>&nbsp;due to&nbsp;<strong>decreased renal synthesis of 1,25-dihydroxyvitamin D<\/strong>&nbsp;(calcitriol, active form). Reduced calcitriol production decreases intestinal calcium absorption, leading to&nbsp;<strong>hypocalcemia&nbsp;<\/strong>and stimulation of&nbsp;<strong>parathyroid hormone<\/strong>&nbsp;(PTH) secretion. In addition, phosphate retention in chronic kidney disease causes&nbsp;<strong>hyperphosphatemia<\/strong>, which further stimulates PTH secretion.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Osteitis fibrosa cystica<\/strong>&nbsp;is a skeletal disorder caused by&nbsp;<strong>chronic elevation of PTH<\/strong>, leading to increased osteoclastic bone resorption, bone pain, fractures, and brown tumors.&nbsp;(as seen in this patient).&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><strong>Secondary hyperparathyroidism<\/strong>\u00a0commonly occurs in patients with\u00a0<strong>chronic kidney disease<\/strong>\u00a0and is characterized by\u00a0<strong>elevated PTH<\/strong>,\u00a0<strong>low serum calcium, and elevated serum phosphate<\/strong>. Chronic PTH excess can lead to\u00a0<strong>osteitis fibrosa cystica.<\/strong>\u00a0<\/strong><\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Review this Osmosis content: <\/strong><a href=\"https:\/\/www.osmosis.org\/learn\/Hyperparathyroidism:_Clinical_sciences\">Hyperparathyroidism: Clinical sciences<\/a><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Bilezikian, J.P., Bandeira, L., Khan, A., Cusano, N.E. (2018)\u00a0<strong>Hyperparathyroidism<\/strong>.\u00a0<em>Lancet<\/em>. 391(10116), 168-178. Doi: 10.1016\/S0140-6736(17)31430-7.\u00a0<\/li>\n\n\n\n<li>Lofrese, J.J., Basit, H., Lappin, S.L. (2019)\u00a0<strong>Physiology, Parathyroid.<\/strong>\u00a0<em>StatPearls\u00a0[Internet]<\/em>. Web Address:\u00a0<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK482510\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK482510\/<\/a>.\u00a0<\/li>\n\n\n\n<li>Moschella, C. (2016)\u00a0<strong>Chronic kidney disease- mineral and bone disorder: Guidelines for diagnosis, treatment, and management.<\/strong>\u00a0<em>Journal of the American Academy of Physician Assistants<\/em>. 29(7), 21-29. Doi: 10.1097\/01.JAA.0000484297.49157.9b.<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image aligncenter size-large\"><a href=\"http:\/\/osmosis.org\/plans\/pa\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?w=700\" alt=\"\" class=\"wp-image-5904\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2020\/09\/Blog_Display_Ads_MD1_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><strong><em>Get your&nbsp;<a href=\"http:\/\/osmosis.org\/plans\/pa\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a>&nbsp;today to discover why millions of clinicians and caregivers love learning by Osmosis.<\/em><\/strong><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A patient on long-term dialysis develops progressive muscle weakness, bone pain, and abnormal hand imaging. Can you identify the laboratory pattern most consistent with the underlying condition?<\/p>\n","protected":false},"author":208,"featured_media":11055,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[20,38,1371,37,1366],"tags":[2967,1951,3387,489,3108,3388,2801,1829,3389,3244,462,280,3390,1949,967],"class_list":["post-11050","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-exam-prep","category-pance","category-pance-questions","category-pa","category-questions","tag-board-exam-prep","tag-calcium","tag-chronic-kidney-disease","tag-clinical-reasoning","tag-clinical-vignette","tag-dialysis","tag-endocrinology","tag-esrd","tag-metabolic-bone-disease","tag-nephrology","tag-osmosis","tag-pance","tag-parathyroid-hormone","tag-phosphate","tag-physician-assistant-education"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - 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