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A CLINICAL PROBLEM-SOLVING article by Ilan Gabriely from Montefiore Medical Center, Bronx, New York.
A 41-year-old woman was brought by her husband to the emergency department with a history of 72 hours of epigastric pain, nausea, repeated vomiting, and altered mental status. Her blood calcium was found to be 18.9 mg per deciliter.
The physical examination was consistent with a hypovolemic state.
The patient's husband reported that 4 days earlier they had returned from a vacation in Central America, where the patient had consumed “a lot of alcohol.” 3 days earlier, she started having severe abdominal pain, followed by multiple episodes of vomiting.
A few months earlier, she had been told by her primary care physician that she had a mildly elevated blood calcium level of 10.9 mg per deciliter. Her physician was reported that her intact parathyroid hormone (PTH) blood level at her last examination was 33.9 pg per milliliter (normal range, 7 to 53). Medications at home included Tums as needed for abdominal pain and a multivitamin. Habitually, she had been drinking 2 to 3 shots of vodka and some wine daily.
Hypercalcemia of this degree is a medical emergency. The patient with severe hypercalcemia is invariably dehydrated, and the first line of treatment should be vigorous hydration with intravenous normal saline with close observation of blood electrolytes and renal function.
The history of a measurable PTH level in the face of elevated blood calcium suggests that the patient may have primary hyperparathyroidism. The level of hypercalcemia in this case, however, would be extremely rare with primary hyperparathyroidism.

TumsというOTC薬の使用を聞き出せるかどうかが、分かれ道。