A 68-year-old man is constipated and confused. Calcium is 3.3 mmol/L. How would you manage him?

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A calcium of 3.3 with confusion represents severe symptomatic hypercalcaemia requiring urgent management. ABCDE with cardiac monitoring, as hypercalcaemia can shorten QT and predispose to arrhythmias. First-line is aggressive IV 0.9% saline rehydration to correct dehydration and promote renal calcium excretion, with careful fluid balance in an older patient. Simultaneously send urgent PTH, renal function, phosphate, vitamin D and consider myeloma screening; a suppressed PTH suggests malignancy whereas an inappropriately normal or elevated PTH points to primary hyperparathyroidism. If calcium remains significantly elevated after rehydration, or malignancy is suspected, I would give IV bisphosphonate such as zoledronic acid, understanding full effect takes 24–48 hours. In refractory cases calcitonin or steroids may be considered depending on cause. So management involves urgent rehydration, cause identification and targeted therapy.

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