Let's go on to another case.
A 71-year old man presents to the emergency
department with shortness of breath,
cough with blood-tinged sputum
and moderate confusion.
His wife notes that he had 16 lbs of
unintentional weight loss over the past year.
He has a 55 pack-year
His exam reveals a thin male in
moderate respiratory distress.
His vital signs are remarkable
for a blood pressure of a 105/70
and a respiratory rate of
20 breaths per minute.
His exam is also significant for decreased
breath sounds over the right upper lobe.
His labs reveal a calcium level of 14.4
mg/dL and a creatinine of 1.6 mg/dL.
His chest x-ray shows a 4 cm spiculated
mass in the right upper lobe.
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.
His exam shows the signs of weight loss and focal
lung findings as well as low blood pressure.
Labs are notable for a very high
calcium and increased creatinine
and a worrisome lung
mass on chest x-ray.
This patient has squamous cell carcinoma
of the lung but not only that.
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.
and that would be the next step in management
in this patient, so check for a PTHrP.
Clinical diagnosis of squamous cell carcinoma
and PTHrP associated severe hypercalcemia
with concomitant renal failure
is the conclusion to this case.
Dehydration has caused the confusion
and the low blood pressure
caused by the calciuresis induced
by the high calcium state.
Treatment immediately would be to volume
resuscitate the patient with intravenous saline.
Intravenous bisphosphonates and
calcitonin may also be further required
to maintain low levels of calcium
and improve bone health.