Question of the Week # 445

445) A 45 year old african-american man presents to the emergency room with altered mental status. His past medical history is significant for skin nodules. One of the nodule was recently biopsied and it revealed non-caseating granuloma. On examination, his oral mucosae are dry.  Blood pressure is 90/60 . Skin examination  reveals multiple scattered skin nodules about 1 to 2cm in diameter. Chest X-ray reveals bilateral hilar adenopathy.   Laboratory Studies reveal

WBC 5400/µl

HGB: 11.8 gm%,

Platelets : 300k/µl

Calcium 14.2gm%

Creatinine 3.2mg%

Phosphorous 2.2mg%

He is started on agressive intravenous hydration. In addition to the above  measures, you should also proceed with  intervention directed to towards which of the following at this time ?

A) Reducing serum phosphorous

B) Reducing serum parathyroid hormone

C) Reducing Blood Calcitrol level

D) Promoting loop diuresis

E) Direct removal of calcium by Hemodialysis

19 Responses

  1. D) Promoting loop diuresis to remove the hypercalcemia, along with intensive hydration

  2. D

  3. E

  4. E.
    not “D” for 2 reasons:
    1) BP is low (90/60) thus you can put the pt. is shock if try to dehydrate him although you are trying to help excrete Calcium.
    2) Calcium level is too high and had already caused the pt. to be in AMS, thus the best and fastest way to rid of Calcium after hydration is to dialyze Calcium out.

  5. D

  6. D

  7. Hydration and diuretic is ok

  8. D loop diuretics!

  9. looking like SARCOIDOSIS

  10. D because the problem has renal failure and sever hyperglycemia. Needs dialysis

  11. Dr. what is the ans???


  12. d is the ans

  13. E is the answer. Regular approach to hypercalcemia is definitely through loop diuretics. But this patient is with renal failure. So it’s dialysis that can save him.

  14. Hemodialysis or peritoneal dialysis with low calcium levels in the dialysis fluid is effective for removing calcium from the circulation. These methods are used for patients with renal insufficiency and congestive heart failure when saline infusion is not feasible

  15. How do i get to know weather my answer is right or wrong?Is there any representative of Archers who is posting the correct answer?

  16. lab values for renal failure??

  17. this patient probably has Sarcoid disease and has developed hypercalcaemia, causing AMS, based on the lab values this patient has also developed ARF, therefore loop diuresis is pretty redundant here, and thus requires hemo or peritoneal dialysis to remove the calcium from the circulation, it would be acceptable? if there was mild renal insufficiency for loop diuresis as you agressively hydrate for hypercalcaemia but you have to be careful not to put the patient into shock, over diuresis also can cause severe renal insufficiency.

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