A 76-year-old man is brought to the emergency department by his son due to progressive lethargy and poor oral intake. The son says the patient has had poor appetite, fatigue, constipation, frequent urination, and possible weight loss. The patient lives with his wife, who suffers from mild dementia. He smokes half a pack of cigarettes a day and drinks a 6-pack of beer on weekends. The patient takes over-the-counter painkillers for occasional back pain and antacids for heartburn. Temperature is 36.9 C (98.5 F), blood pressure is 140/90 mm Hg, pulse is 96/min, and respirations are 14/min. Pulse oximetry shows 95% on room air. He is oriented to person only. Mucous membranes appear dry, and the neck is supple. The lungs are clear on auscultation. There are no heart murmurs. The abdomen is soft, and no masses are palpable. The patient moves all of his extremities on command. Laboratory results are as follows: The patient is started on normal saline and calcitonin. Twelve hours later, blood urea nitrogen is 30 mg/dL, serum creatinine is 1.4 mg/dL, and serum calcium is 15 mg/dL. Which of the following additional measures is recommended at this time for this patient?

Question

A 76-year-old man is brought to the emergency department by his son due to progressive lethargy and poor oral intake.  The son says the patient has had poor appetite, fatigue, constipation, frequent urination, and possible weight loss.  The patient lives with his wife, who suffers from mild dementia.  He smokes half a pack of cigarettes a day and drinks a 6-pack of beer on weekends.  The patient takes over-the-counter painkillers for occasional back pain and antacids for heartburn.  Temperature is 36.9 C (98.5 F), blood pressure is 140/90 mm Hg, pulse is 96/min, and respirations are 14/min.  Pulse oximetry shows 95% on room air.  He is oriented to person only.  Mucous membranes appear dry, and the neck is supple.  The lungs are clear on auscultation.  There are no heart murmurs.  The abdomen is soft, and no masses are palpable.  The patient moves all of his extremities on command.  Laboratory results are as follows:  The patient is started on normal saline and calcitonin.  Twelve hours later, blood urea nitrogen is 30 mg/dL, serum creatinine is 1.4 mg/dL, and serum calcium is 15 mg/dL.  Which of the following additional measures is recommended at this time for this patient?

Quizplus · Accepted Answer

11ec193a_96ab_5169_853d_ff58a56ea406_MD0002_00 Hypercalcemia >13 mg/dL is most often due to malignancy. Most patients with this degree of hypercalcemia are volume-depleted from vomiting and renal salt and water wasting. The initial step in management is to restore intravascular volume with normal saline, which promotes urinary calcium excretion. Calcitonin is also administered early in management and can rapidly lower serum calcium levels by decreasing bone resorption. In addition to these initial measures, bisphosphonates (eg, zoledronic acid) should be given concurrently and will further decrease bone resorption. Bisphosphonates require 2-4 days to affect serum calcium levels but provide a sustained calcium-lowering effect. Although zoledronic acid is not recommended for use in non-oncologic conditions (eg, osteoporosis), if creatinine clearance is <35 mL/min (or <30 mL/min in multiple myeloma or known bone metastasis), it may be used for humoral hypercalcemia of malignancy in patients with significant renal impairment (serum creatinine <4.5 mg/dL) and may be considered for those with serum creatinine >4.5 mg/dL. < (Choice A) Denosumab is a monoclonal antibody that inhibits osteoclast maturation and consequently slows bone breakdown. It is not recommended as first-line treatment for hypercalcemia of malignancy but can be considered for patients with hypercalcemia refractory to bisphosphonates or for those with severe renal impairment (serum creatinine >4.5 mg/dL). (Choice B) Furosemide has been advocated to promote urinary calcium excretion but is associated with electrolyte disturbances (eg, hypokalemia) and can worsen hypovolemia. It is typically reserved for patients who develop volume overload. (Choice C) Hemodialysis with a calcium-free dialysate is used for patients with severe renal dysfunction or heart failure in whom adequate intravenous saline hydration cannot be safely administered. (Choice D) Corticosteroids (eg, methylprednisolone) are effective in treating hyperabsorptive hypercalcemia due to vitamin D toxicity, lymphoma, or granulomatous disease (eg, sarcoidosis). However, the response to corticosteroids can be variable, and they are not recommended for treatment of hypercalcemic emergencies of unknown origin. Educational objective: The initial management of severe hypercalcemia (>13 mg/dL) includes saline hydration to promote urinary calcium excretion and calcitonin to decrease bone resorption. Bisphosphonates require 2-4 days to affect serum calcium levels but should be given concurrently to provide a sustained calcium-lowering effect. __________ References: Hypercalcemia in the intensive care unit: a review of pathophysiology, diagnosis, and modern therapy. (http://www.ncbi.nlm.nih.gov/pubmed/24130250)

A 76-Year-Old Man Is Brought to the Emergency Department by His