Self-assessment Cases

Chapter 17 Managing hypercalcaemia of malignancy

A 68-year-old woman with a diagnosis of breast carcinoma and liver metastases presents with an overall deterioration in her condition which has occurred over the last week. She reports feeling nauseated and vomits on occasions. Her usual antiemetic treatment is not effect. She is dehydrated and she has been passing a lot of urine. She also feels constipated. She is generally more uncomfortable. She is easily fatigued and her family says she is a little confused at times. Previously, she was very active and was relatively asymptomatic.

• 1. What do you feel may have resulted in this deterioration?

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  Correct answer:
  This presentation is vague and may be due to many causes including sepsis, constipation, brain metastases, opiate toxicity and hyperglycaemia. It may indicate that she is beginning to die? It is important to check her serum calcium levels to ensure that the presentation is not due to hypercalcaemia which is treatable.

• 2. On history and examination what would you be paying particular attention to?

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  • Signs of sepsis – respiratory, urinary or wound infections
  • Bowel history, use of laxatives and examination of her abdomen
  • Examine for signs of dehydration including skin turgidity and dry mucous membranes
  • Observe for signs of ‘twitching’ or brisk reflexes
  • Observe her mental state for signs of agitation, delirium and paranoia
  • Review her medications

• 3. What investigations would you expect this patient to need initially?

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  Correct answer:
  

  • Routine clinical observations (Blood pressure and temperature)
  • Blood glucose level
  • Test urine for signs of infection or glycosuria
  • Bloods for FBC, U&E and serum calcium

• 4. What treatment would you expect she would receive for her hypercalcaemia?

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  Correct answer:
  

  • Hydration by the most appropriate route. Observe for signs of circulatory overload and urea and electrolyte balance.
  • If her renal function allows, treat with IV bisphosphonates.
  • Treat her for nausea, discomfort and constipation.
  • Administer bisphosphonates.

• 5. When you review her medication list what medications would you pay particular attention to in relation to hypercalcaemia?

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  Correct answer:
  

  • Thiazide diuretics and Vitamins A and D – these drugs promote hypercalcaemia.
  • Hormonal agents may exacerbate hyperglycaemia.
  • Digoxin – its effect is potentiated by hypercalcaemia and may need to be adjusted.