394 Emergency Medicine
patient has no risk factors and has a better alternative diagnosis based on
history and physical examination findings.
362.The answer is b.(Tintinalli et al, p 176.)This common presentation
ofhypercalcemiais initially managed with aggressive isotonic saline IV
hydrationto restore volume status. Hypercalcemia impairs renal concen-
trating ability, and patients typically present with polyuria, polydipsia,
anddehydrationand may develop kidney stones.Increased calcium
levels also cause generalized weakness, bone pain, neurologic symptoms
(ataxia, altered mental status), GI dysfunction (abdominal pain, nausea, vom-
iting, anorexia), and ECG abnormalities (shortened QT interval). A handy
mnemonic for symptoms of hypercalcemia is “bones, stones, groans, and psy-
chiatric overtones.”
Calcitonin(a)decreases calcium levels by reducing bony osteoclast
activity and intestinal calcium absorption. It does not produce an immediate
effect and is generally not started in the ED. Loop diuretics such as furosemide
(c)increase renal elimination of calcium but worsen volume depletion.
Patients need to be hydrated first. Obtaining a chest radiograph (d)is a good
idea while the patient is getting IV hydration. This patient has a significant
smoking history and recent weight loss which should raise your suspicion
of a neoplastic lung process causing hypercalcemia. Malignancy is an
important cause of hypercalcemia; others include endocrine abnormalities
(hyperparathyroidism, hyperthyroidism, pheochromocytoma, adrenal insuf-
ficiency), granulomatous disease (sarcoidosis, tuberculosis), drugs (thiazides,
lithium), and immobilization. The patent’s ECG (e)may show a shortened
QT interval. Very high calcium levels may cause heart block.
363.The answer is c.(Tintinalli et al, p 1463.)Unilateral findings of ptosis
and miosis as well as anhidrosis are seen in Horner syndromewhich results
from interrupted sympathetic nerve supply to the eye.
Palsy of the oculomotor nerve results in a “down and out” eye because
of the dysfunction of the extraocular muscles innervated by the oculomotor
nerve. In addition, the pupil appears mydriatic as a result of the loss of
function of the ciliary parasympathetic nerves. Ptosis is common because
the oculomotor nerve innervates the levator palpebrae. Homan sign (a)refers
to leg pain with dorsiflexion of the foot sometimes seen in patients with deep
venous thrombosis. This sign has poor sensitivity and specificity. Bell palsy
(b)involves unilateral facial paralysis as a result of peripheral involvement of
the facial nerve. In patients with a central facial nerve lesion the forehead is