A case of hypercalcemia

A case of hypercalcemiaA case presentation by cabalona, demecillo, escarda, salazar, yanoGood afternoon consultants, residents, PGIs and co-interns. Our group will be presenting a case of hypercalcemia. 1General objective:To present a case of C.N., a 40-year old, male, presenting with hypercalcemia2Specific objectives: To be able to present the patients profile, history of present illness, physical examination and clinical formulation, To be able to present the patients course in the ward, To be able to discuss the etiology, pathogenesis, diagnosis, clinical manifestations and management of the hyperparathyroidism, To be able to discuss the current diagnostic evaluation and treatment recommended for the patients disease.

Patients Profile C.N. 40/M Married, Filipino, Roman Catholic Security guard Cabantan St., Barrio Luz, Cebu City Admitted for the 1st time on June 23, 2015 reason for admission: hypercalcemiaThis is a case of C.N., a 40 year old male, married, Filipino, Roman Catholic, security guard, currently residing at Cabantan St., Barrio Luz, Cebu City, admitted for the 1st time here at CHH on June 23, 2015 due to hypercalcemia.4History of present illnesssought consult at CHH for recurrent attack of gouty arthritiswork-up was done which revealed a high serum creatinine level - unrecalled levelreferred to a nephrologistadditional labs were taken which revealed high calcium level unrecalled level(-) fever, dyspnea, nausea and vomiting or changes in bladder and bowel habitsno medications taken4 months5History of present illness4 months PTA2 months PTAPatient went back to his doctor for follow-up. A series of labs were done.

Whole abdominal ultrasound: Diffuse fatty changes of the liver Cholelithiasis without evidence of cholecystitis Nephrocalcinosis with nephrolithiasis of both kidneys Bilateral simple renal cortical cysts Enlarged prostate gland (Grade I) with no calcification

7UTZ of the neck Slightly enlarged thyroid gland and multifocal lesions probably adenomatous/colloid/hyperplasia, some undergoing cystic degeneration, seen on a background with normal thyroid parenchyma consider parathyroid nodules vs enlarged para-tracheal lymph nodes, inferior, superior portions, R side

April 7, 2015TestResultReference rangeUrea nitrogen34.8 mg/dl7.0-18.0Creatinine7.2 mg/dl0.6-1.5Ionized calcium1.9 mmol/L0.9-1.4TestResultReference rangeIntact PTH921.1 pg/mlMale: 15-65 April 8, 2015TestResultReference rangeUrea nitrogen33.4 mg/dl7.0-18.0Creatinine5.7 mg/dl0.6-1.5Uric acid7.5 mg/dl3.0-8.0Albumin3.5 g/dl3.5-5.0Total calcium12.9 mg/dl8.4-10.4TestResultReference rangeThyroid function test FT4 FT3 TSH 9.13 pmol/l4.25 pmol/l0.757 IU/mlMale: 15-65 11.0-22.53.1-6.50.30-5.0April 10, 2015TestResultReference rangeUrea nitrogen37.2 mg/dl7.0-18.0Creatinine5.9 mg/dl0.6-1.5Total Calcium13.5 mg/dl8.4-10.4Sodium138.0 mmol/l134-148Potassium4.3 mmol/l3.3-5.3April 11, 2015 TestResultReference rangeTotal Calcium13.2 mg/dl8.4-10.4TestResultReference rangeThyroid function test FT410.68 pmol/l11.0-22.5April 20, 2015TestResultReference rangeTotal Calcium12.2 mg/dl8.4-10.4Potassium5.3 mmol/l3.3-5.3April 20, 2015TestResultReference rangeUrea nitrogen49.9 mg/dl7.0-18.0Creatinine5.3 mg/dl0.6-1.5Albumin2.4 g/dl3.5-5.0Total Calcium13.7 mg/dl8.4-10.4Potassium3.8 mmol/l3.3-5.3History of present illness4 months PTA2 months PTAPatient went back to his doctor for follow-up. A series of labs were done. Advised admission & surgeryPast Medical History Hypertensive for 16 years now, HBP: 200/120 mmHg, UBP: 160/80 mmHg Metoprolol (Neobloc) 50mg/tab 1 tab OD PO, poor compliance Non-diabetic, non-asthmatic No known food and drug allergies Abdominal hernia repair unrecalled year Renal stones 25 yo, passed out grain sized white hard stones Gouty arthritis 27 yo, self-medicated with Ibuprofen (Alaxan FR), Diclofenac Athrocentesis of the left knee 2013

Patient is a known hypertensive since he was 24 years old, with highest recorded BP of 200/120 and usual BP of 160/80. His maintenance medication is Metoprolol (Neobloc) 50 mg/tab 1 tab OD PO, taken with poor compliance. He is non-diabetic and non-asthmatic and has no known food and drug allergies. Previous hospitalizations include during an unrecalled year at Perpetual Soccour Hosp for repair of abdominal hernia. Patient shared about a had a history of passing out white-colored stones while voiding urine when he was still 25 yo. This recurred 3-4/year. This was associated with pain upon urination but was just tolerated. No medications were taken, no consult was done. Patient was diagnosed with gouty arthritis when he was still 27 yo. He self-medicated with Ibuprofen (Alaxan) and Diclofenac during attacks. Last 2013, he underwent arthrocentesis of the left knee at CHH.

16Personal/Social history Former hotel attendant in Riyadh, Saudi Arabia for 6 years Currently a security guard at Marriott Hotel Former cigarette smoker with 25.5 pack year history Former heavy alcoholic beverage drinker; drank 3x a week to the point of intoxication stopped last 2014 History of Methamphetamine and Cannabis use Usual diet consists of rice, vegetables and fish, rarely meat; Water intake: 3-5 L of water No herbal supplements Urinates > 10 times per day; Regular bowel movementHeredofamilial diseases Hypertension, Diabetes, Bronchial asthma paternal & maternal Prostate cancer paternal Parathyroid pathologies paternal Thyroid cancer - MotherReview of SystemsGeneral: recent weight loss of approximately 30 kilograms in 1 year

Skin: dry, (-) rashes, lumps, sores, pruritus, changes in color, changes in the hair or nails

Head: (-) headache, head trauma, dizziness, and lightheadedness

Eyes: (-) vision changes, eye pain , redness, excessive tearing, blurred vision, development of cataracts, glaucoma

Ears: (-) tinnitus, vertigo, ear pain, infections and discharges

Nose and Sinuses; (-) frequent colds, nasal congestion, discharges, sinusitis

Mouth and Throat: (-) cyanosis, dry mouth, bleeding gums, sore throat, hoarseness

Review of SystemsNeck: (-) history of goiter, (-) palpable lumps, lymph nodes and neck stiffness

Respiratory: (-) cough, hemoptysis, dyspnea, wheezing

CVS: (-) high blood pressure, rheumatic fever, heart murmurs, PND

GI: polydipsia, (-) nausea, vomiting, polyphagia; (-) dysphagia, heartburn, changes in bowel habits, anorexia

GUT: (+) polyuria, nocturia; (-) urinary urgency, dysuria, hematuria, incontinence, dribbling and hesitancy

PVS: (-) Intermittent claudication, cramping, tingling and numbness, varicosities

Review of SystemsMS: (+) joint pain on both knees, (-) weakness, (-)muscle pains, stiffness, history of trauma

CNS: (-) changes in sensorium, syncope, seizures, paralysis, numbness or loss of sensation, and aphasia

Hematologic: (-) anemia, easy bruising, prolonged bleeding , blood transfusions

Endocrine: (-) history of goiter; (-) Diabetes

Psychiatric: (-) history of psychiatric illnesses

Physical ExaminationGeneral survey: Awake, alert, afebrile, sthenic, not in respiratory distressVital signs: T: 36.8 degrees Celsius, RR: 22 cpm, PR: 102 bpm, BP: 120/80 mmHgSkin: Warm, Dry , Rough, Senile turgor, No lesionsHEENT: No gross deformities, No lesions on the scalp, Equal palpebral fissures, white sclerae, pink palpebral conjunctivae, clear lens, equally round and reactive pupil, no nasoaural discharges, pink, moist lips, normal oral mucosa, non inflamed tonsilsNeck: Supple, trachea at midline, non-palpable thyroid, no engorged neck veins

Physical ExaminationChest and lungs: no gross deformities, no abnormal retractions, no areas of tenderness, resonant, clear breath sounds, (-) rales, (-) wheezeCVS: adynamic precordium, PMI located at the 5th LICS MCL, < 2.5 cm in diameter, distinct S1&S2 sounds, HR: 106 bpm, no murmurAbdomen: flabby, 5 cm linear supra-umbilical scar, normoactive bowel sounds, generally tympanitic except at area of liver dullness (LAD: 4CM-MSL, 8CM-MCL); soft and nontender; no organomegalyGUT: (-) KPS bilaterally Extremities: (+) Grade 1 bipedal pitting edema, no gross deformities, CRT < 2 seconds, strong peripheral pulses, no clubbing

Assessing pitting edemaGrade 1