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Clinical Case 2
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Objectives:

  • Recognize the most common causes of hypercalcemia
  • Identify presenting symptoms of hypercalcemia
  • Understand the mechanisms underlying hypercalcemia in malignancy
  • Initiate emergency treatment for symptomatic hypercalcemia
  • Identify the most common tumors associated with hypercalcemia



1

A 78-year-old female is brought to the emergency room for strange behavior. According to her family, she has been more sleepy throughout the last week. She is acting more withdrawn and depressed and seems to respond to nonexistent external stimuli. When asked about her depression, she reports she is sad because voices are telling her she’s going to die. She has been very weak, especially the last day or two. The patient complains of abdominal cramps and blames it on “being plugged up,” and her family reports no bowel movement for 2 days. She also notes chronic bone pain in her hips and back.

A physical exam is notable only for a 3 cm irregular mass in her right breast. The patient denies noticing this before. Her neurological exam is normal, except for her apparent confusion.

What finding would you expect from an ECG?
A)Peaked T-waves.
B)Diffuse ST-segment elevations.
C)Long QT interval.
D)Short QT interval.
E)Second degree Mobitz II block.
2

What laboratory tests should now be done?
A)Electrolytes, including a calcium level.
B)Complete blood count.
C)TSH.
D)Chest x-ray.
E)All of the above.
3

Your patient’s calcium level is reported as 15.3 mg/dL (elevated).

What is the next step in her treatment?

A)Moderately aggressive normal saline hydration.
B)IV chlorthalidone administration.
C)IV calcitonin administration.
D)IV bisphosphonate infusion.
E)Gallium nitrate infusion.
4

The patient is treated appropriately for her hypercalcemia and her mental status improves. A biopsy of her breast mass is done and reveals an infiltrating ductal carcinoma. A bone scan reveals diffuse metastatic disease.

Which of the following statements about the mechanism for malignancy associated with hypercalcemia is (are) true?

A)Decreased bone reabsorption increases the serum calcium.
B)Secretion of osteoclast-inhibiting factors increases the serum calcium.
C)Secretion of PTH-like substances increases the serum calcium.
D)Direct erosion of bone by tumor cells never plays a role.
E)All of the above.
5

Your patient’s cancer cannot be cured. How can her chronically elevated calcium level be managed?
A)Oral glucocorticoids.
B)Oral phosphates.
C)Oral bisphosphonates.
D)Avoid any medications known to cause hypercalcemia.
E)All of the above.





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