Bone Metabolism Case: 71-year-old Man with Shortness of Breath

00:01 Let's go on to another case.

00:03 A 71-year old man presents to the emergency department with shortness of breath, cough with blood-tinged sputum and moderate confusion.

00:11 His wife notes that he had 16 lbs of unintentional weight loss over the past year.

00:17 He has a 55 pack-year smoking history.

00:21 His exam reveals a thin male in moderate respiratory distress.

00:26 His vital signs are remarkable for a blood pressure of a 105/70 and a respiratory rate of 20 breaths per minute.

00:33 His exam is also significant for decreased breath sounds over the right upper lobe.

00:39 His labs reveal a calcium level of 14.4 mg/dL and a creatinine of 1.6 mg/dL.

00:47 His chest x-ray shows a 4 cm spiculated mass in the right upper lobe.

00:52 What is the next step in the management of this patient? In reviewing the symptoms and examination of this patient, we have an elderly smoker who presents with hemoptysis.

01:04 His exam shows the signs of weight loss and focal lung findings as well as low blood pressure.

01:11 Labs are notable for a very high calcium and increased creatinine and a worrisome lung mass on chest x-ray.

01:20 This patient has squamous cell carcinoma of the lung but not only that.

01:24 He is manifesting with severe hypercalcemia and we always worry about a paraneoplastic manifestation of squamous cell carcinoma of the lung which is the secretion of parathyroid hormone releasing peptide.

01:38 and that would be the next step in management in this patient, so check for a PTHrP.

01:43 Clinical diagnosis of squamous cell carcinoma and PTHrP associated severe hypercalcemia with concomitant renal failure is the conclusion to this case.

01:54 Dehydration has caused the confusion and the low blood pressure caused by the calciuresis induced by the high calcium state.

02:03 Treatment immediately would be to volume resuscitate the patient with intravenous saline.

02:09 Intravenous bisphosphonates and calcitonin may also be further required to maintain low levels of calcium and improve bone health.