63 year old lady with abdominal pain and mild confusion

Samuel Wilson on May 26, 2013

You review her Past Medical History which is significant for hypertension, hyperlipidemia. She takes captopril, hydrochlorothiazide, atorvastatin, and a multivitamin. You review her Past Surgical History, Allergies/Intolerances, Family History which is unchanged and noncontributory. With respect to Social History, she is a 1 pack per day smoker with a 50 pack year history. She consumes 1-2 alcoholic beverages per month and denies any illicit drug use. She lives at home with her husband who she reports is healthy.

You review her vitals for today:

  • Temp  37 C
  • HR  95
  • BP  118/76
  • RR  12
  • O2  97% on Room Air

On physical exam, you note:
General: Well appearing, pleasant lady in no apparent distress
HEENT: Normocephalic, atraumatic. No scleral injection or icterus. Pupils are reactive to light and eye movement is preserved. Oropharynx is clear without lesions, mucous membranes are dry. Neck is supple with no signs of thyromegaly. No cervical lymphadenopathy.
CV: Regular rate and rhythm, with normal S1 and S2, without murmurs, rubs or gallops.
Respiratory: Mild diffuse wheezing throughout all lung fields. No rales or rhonchi. Forced expiratory time is around 6 seconds.
Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. Tympanic to percussion. No hepatosplenomegaly or other abdominal masses.
Extremities: 2+ peripheral pulses in dorsalis pedis and radial arteries bilaterally. No skin rashes. No peripheral edema.

 

How would you characterize these physical exam findings?

Expand all answers
Informative, but not diagnostic.
Correct. You’ve learned that she is dehydrated, making it more likely that she has hypercalcemia. However, you still do not know the cause of her probable hypercalcemia.


Worrisome, she needs emergent resuscitation
Not really. Her exam is largely benign except for dehydration. She is not in any signs of distress that suggests she needs emergent resuscitation.


Reassuring, no further investigation is necessary.
Not really. She is having symptoms that are concerning for hypercalcemia and she appears to be dehydrated on exam which is consistent with hypercalcemia.


What single best test should you order next?

Expand all answers
CBC Panel
While this test could be helpful, it most likely will not provide information to help confirm your diagnosis


Basic Panel
Although this test could confirm help your diagnosis, it is missing a key measurement which would be useful to have.


Comprehensive Metabolic Panel
This test includes albumin which helps you determine whether or not the serum calcium measurement is accurate.


Chest x-ray
While this is an important study to get, this should be delayed until the immediate issue is taken care of.


Brain MRI
Incorrect, no indication for this study.


TSH
This test might be important to order if your primary diagnosis is ruled out.


You review her Past Medical History which is significant for hypertension, hyperlipidemia. She takes captopril, hydrochlorothiazide, atorvastatin, and a multivitamin. You review her Past Surgical History, Allergies/Intolerances, Family History which is unchanged and noncontributory. With respect to Social History, she is a 1 pack per day smoker with a 50 pack year history. She consumes 1-2 alcoholic beverages per month and denies any illicit drug use. She lives at home with her husband who she reports is healthy.

You review her vitals for today:

  • Temp  37 C
  • HR  95
  • BP  118/76
  • RR  12
  • O2  97% on Room Air

On physical exam, you note:
General: Well appearing, pleasant lady in no apparent distress
HEENT: Normocephalic, atraumatic. No scleral injection or icterus. Pupils are reactive to light and eye movement is preserved. Oropharynx is clear without lesions, mucous membranes are dry. Neck is supple with no signs of thyromegaly. No cervical lymphadenopathy.
CV: Regular rate and rhythm, with normal S1 and S2, without murmurs, rubs or gallops.
Respiratory: Mild diffuse wheezing throughout all lung fields. No rales or rhonchi. Forced expiratory time is around 6 seconds.
Abdomen: Soft, nontender, nondistended. Normoactive bowel sounds. Tympanic to percussion. No hepatosplenomegaly or other abdominal masses.
Extremities: 2+ peripheral pulses in dorsalis pedis and radial arteries bilaterally. No skin rashes. No peripheral edema.

 

How would you characterize these physical exam findings?

Expand all answers
Informative, but not diagnostic.
Correct. You’ve learned that she is dehydrated, making it more likely that she has hypercalcemia. However, you still do not know the cause of her probable hypercalcemia.


Worrisome, she needs emergent resuscitation
Not really. Her exam is largely benign except for dehydration. She is not in any signs of distress that suggests she needs emergent resuscitation.


Reassuring, no further investigation is necessary.
Not really. She is having symptoms that are concerning for hypercalcemia and she appears to be dehydrated on exam which is consistent with hypercalcemia.


What single best test should you order next?

Expand all answers
CBC Panel
While this test could be helpful, it most likely will not provide information to help confirm your diagnosis


Basic Panel
Although this test could confirm help your diagnosis, it is missing a key measurement which would be useful to have.


Comprehensive Metabolic Panel
This test includes albumin which helps you determine whether or not the serum calcium measurement is accurate.


Chest x-ray
While this is an important study to get, this should be delayed until the immediate issue is taken care of.


Brain MRI
Incorrect, no indication for this study.


TSH
This test might be important to order if your primary diagnosis is ruled out.


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