Internal Medicine Case Challenge: Hallucinations, Moaning, and Confusion in an 88-Year-Old

Danny Gersowsky, DO


May 10, 2023


In this case, the patient had multiple pathologies and diagnoses, including acute renal failure, DVT, sepsis secondary to the infected sacral ulcer, and hypercalcemia. This discussion will focus specifically on the management of hypercalcemia.

In the emergency department, she was given a 30 cc/kg fluid bolus of normal saline, cefepime 2 g, and vancomycin 20 mg/kg for suspected sepsis. A heparin drip was started to treat the pulmonary embolism. The patient was subsequently admitted to the ICU, where she received another 2-L fluid bolus, and shortly thereafter, dextrose 5% half normal saline maintenance fluid was started. No other treatment for hypercalcemia was given on day 1 of her hospital stay.

The next day in the ICU, the patient's calcium level was 17.3 mg/dL (reference range, 9-10.5 mg/dL). Intravenous calcitonin 4 IU/kg every 12 hours was started. The next day, her calcium level increased to 18.2 mg/dL; the ionized calcium level was 11.92 mg/dL (reference range, 4.5-5.6 mg/dL). Her parathyroid hormone level was 1141 pg/mL (reference range, 10-65 pg/mL). Given these findings, the nephrology service was consulted for suspected primary hyperparathyroidism. Cinacalcet 60 mg twice daily was ordered as well as sestamibi imaging and a parathyroid ultrasound to evaluate the parathyroid glands to confirm primary hyperparathyroidism. The next day, her calcium level was 18.1 mg/dL, and she received hemodialysis. Plans were made concomitantly for a parathyroidectomy.


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