I saw L for consultation just yesterday. He has a history of prostate cancer who for the last 6 months has been having back pains. Conveniently treated by his chiropractor, who said he didn't need to see his doctor (mistake #1). After 6 months of manipulation he didn't feel better, and so finally sees his GP. In the meantime he has gotten weaker, and has been feeling pretty nauseated. GP orders labs, serum Calcium comes back 15.5 mg/dL and he is in acute renal failure. "It must be your parathyroids. I'll just refer you to an endocrinologist." (mistake #2).
Thankfully there was a last minute cancellation on my schedule and he was able to see me within a day (my usual waiting list tends to go out weeks). When I walk into the exam room, he's laying on the exam table, too weak to sit up. Mr. L asks for an emesis basin, and a blanket. Not having too many patients ask for blankets, my room didn't have any fresh ones. I was embarrassed to have use my white doctor's coat to cover him to keep him warm (he didn't mind). He's essentially failed the eyeball test, labs notwithstanding. I literally wheel him to the ER 2 floors down myself for hospital admission; this should not have been an outpatient evaluation to begin with, and his GP should have had more common sense than that. Calcium levels like that can kill.
His Calcium there was 16.3 mg/dL. Expectedly, his PTH was suppressed. Expectedly, ominously, the Phosphorus, Alkaline Phosphatase were up.
I looked at Mr. L's PET-CT results today, and it was the worst report I had ever seen. Diffuse skeletal metastasis, with intense FDG uptake in every vertebral body, as well as other sites.
As a doctor, we all like to be right. We don't like to make mistakes. But times like this, I wish I was dead wrong when my gut told me what the source of his hypercalcemia was.