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

by Michael Lazarus

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    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 acquired to maintain low levels of calcium and improve bone health.

    About the Lecture

    The lecture Bone Metabolism Case: 71-year-old Man with Shortness of Breath by Michael Lazarus is from the course Metabolic Bone Disorders. It contains the following chapters:

    • Case: 71-year-old Man with Shortness of Breath
    • PTHrP Check

    Included Quiz Questions

    1. Check for PTHrP
    2. CT lung screening
    3. Volume resuscitation with IV saline
    4. Bronchoscopy and biopsy of the mass

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

     Michael Lazarus

    Michael Lazarus

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