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

by Michael Lazarus, MD

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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 required 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, MD 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. Parathyroid hormone-related peptide (PTHrp)
    2. Elevated 25-hydroxyvitamin D
    3. Parathyroid hormone-related peptide (PTHrp) and parathyroid hormone (PTH)
    4. Parathyroid hormone (PTH)
    5. Metabolic acidosis due to renal failure

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

     Michael Lazarus, MD

    Michael Lazarus, MD

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