Question

Case Study

Peter, a forty-three year old office worker, was struck with a very sudden and intense pain in his side and lower back. He was breathing deeply, and the pain began to recede. Eight minutes later, the pain was not as severe but Peter was still uncomfortable and called his physician. One of Peters’s colleagues drove Peter to the doctor’s office. While on the way to his appointment, Peter experienced another bout of severe pain and began to feel nauseous. The pain seemed to be spreading into his lower abdomen and groin.

After asking Peter a few questions about his symptoms, the doctor requested an abdominal x-ray, several blood tests, and urinalysis. As Peter supplied the urine sample he was disturbed to notice that the urine had a pinkish cast. The physician returned and informed Peter that he had a kidney stone which, based on its size, should pass on its own within a day or so. The doctor told Peter that he should rest at home until the stone passed, drink at least 2-3 quarts of water each day, and strain his urine in order to retrieve the stone for analysis. The doctor also gave Peter a prescription for pain medication.

Peter passed the stone the following morning and brought it to the doctor’s office. Analysis of the stone’s composition revealed that it was a calcium stone. Peter’s blood and urine tests had also shown high calcium levels. Based on this, the doctor told Peter to eat fewer foods containing calcium or oxalate and provided Peter with a list of foods to limit. He also told Peter to continue to drink at least two quarts of water each day.

Answer 1

Hypercalcemia is characterized as greater than normal amounts of calcium in the blood. Symptoms can effect the musculoskeletal, nervous, cardiovascular/pulmonary, and gastrointestinal systems (see table below). Normal serum calcium levels range between 8.2 and 10.2 mg/dL. Mild hypercalcemia is considered when calcium levels are around 12 mg/dL and severe hypercalcium is defined as serum calcium levels at 14 mg/dL.

System	Symptoms
Central Nervous System (CNS)	drowsiness, lethargy, coma irritability, personality changes, confusion, headaches, depression, memory loss, difficulty concentrating, visual disturbances, balance/coordination problems, changes in deep tendon reflexes, change in muscle tone for individual with neurologic condition, positive Babinski and/or clonus reflex, changes in bowel/bladder function
Musculoskeletal	muscle pain or tenderness and weakness, muscle spasms, bone pain (worse at night and on weight bearing), pathologic fracture
Cardiovascular	Hypertension, Arrhythmia, Cardiac arrest
Gastrointestinal	Anorexia (loss of appetite), nausea, vomiting, constipation, dehydration, thirst

Patient Characteristics

• 43 year old
• White male
• Height: 5' 8" Weight:164
• office worker
• Runs a soup kitchen 3 days/week
• Diagnosis: Hypercalcemia secondary to Vitamin D intoxication & thiazide diuretic
• Past Medical History: Primary hypothyroidism, HTN, hyperlipidemia, & vitamin D deficiency

Examination

• Subjective: Chief Complaint:fatigue, anorexia, nausea, abdominal pain, constipation and depression for 1 month.
• Objective: She appears weak and dry. Vitals: BP: 154/92 RHR: 84 bpm Heart Sounds: audible S1,S2. Lungs were clear to ascultate bilaterally. Alert & oriented x 1 (only person). Oxygen saturation: 95% on room air.

ROM (UE's):  WNL

ROM (LE's): WNL

Gross MMT:  UE: EROT: 4/5 bilaterally, Elbow flexion: 4/5 left, 5/5 right, elbow extension: 4/5, Shoulders, wrists, & grip strength: 5/5 bilaterally. LE: Hip Abduction: 4/5 bilaterally, knee extension: 4/5 on the left & 5/5 on the right, hip flexion, knee flexion, plantar flexion & dorsiflexion 5/5 bilaterally.

Reflexes:  Normal

Sensation: Normal

Posture: elevated/protracted shoulders, forward head position

Gait:  limited bilateral hip extension, decreased bilateral reciprocal arm swing, shortened step length

Static sitting:  normal

Dynamic sitting:  normal

Bed mobility: Independent

Sit to stand: independent

Bed to Chair & Chair to Bed transfer: Independent

Ambulation:  150 feet with contact guard assist

Basic metabolic panel: hypercalcemia 13mg/dl, ionized calcium of 1.8, acute kidney injury with Cr of 2.2 & hyperphoshatemia. Further lab data showed a low PTH & high Vit D levels.

• Self Report/Physical Performance: Visual Analog Scale (VAS) Best: 4/10 Current: 7/10 Worst: 9/10 6 Minute Walk Test - 375 meters
  

Clinical Impression

1) Hypercalcemia & Hyperphosphotemia secondary to Vit D intoxication & thiazide diuretic
2) Acute Kidney injury secondary to Hypercalcemia
3) Dehydration secondary to Hypercalcemia

Summarization of Examination Findings

Based on the subjective and objective findings, the targeted intervention was to rehydrate with normal saline (IVF). In a case of severe hypercalcemia, intervention would include the administration of biphosphonate or calcitonin. The goal for restoration of function of this patient is to rehydrate the patient with normal saline in order to excrete calcium from the renal tubules. It's important to determine the etiology of the hypercalcemia (PTH related on non-PTH related) as the management may vary. Our case is non-PTH related hypercalcemia due to Vit D intoxication. Since the baseline vitals are stable, physical therapy intervention will begin immediately following the effect of medical intervention in order to restore hydration and the process of calcium excretion.

Physical Therapy Intervention

The physical therapy plan of care for this patient will be a one week program (5 days) for the acute care setting.

Frequency:  5 days a week (Monday - Friday)

Outcomes

The patient's vitals remained stable and rehydration through medical intervention occured within 4 to 6 hours. At day 5, calcium levels had reduced to 11mg/dL. The patient's reported VAS score for their current pain level had significantly improved from an intial 7/10 to a 4/10 at day 5. Her reported worst pain level improved from 9/10 to 6/10, and her least level of pain improved from 4/10 to 2/10 respectively. In addition, her aerobic endurance via the 6 Meter Walk Test also improved from 375 feet initially to 425 feet at discharge. Ambulation distance improved from 100 feet with contact guard assist initially to 200 feet with stand by assist upon day 5. The patient demonstrated improved posture and reciprical arm swing and step length during gait with minimal verbal cues. Gross MMT remained unchanged.

Discussion

Although the patient in this case presented with hypercalcemia secondary to vitamin D intoxication, it's critical to have lab work done to establish that her parathyroid levels are within normal range since she had a past medical history of hypoparathyroidism. According to the literature, it's important to reduce or even stop any substitution of calcium and vitamin D metabolites in patients with hypoparathyroidism during periods of immobilization   In addition to improving overall strenght and aerobic conditioning, current research supports physical therapy intervention for the following reasons: immobilization is a well-established but under appreciated etiology of hypercalcemia, immobilization-induced hypercalcemia can obviate the need to order unnecessary examinations, pre-existing renal function impairment are prone to develop immobilization hypercalcemia in a shorter time frame, and the standard treatments for immobilization hypercalcemia include the use of early rehabilitative exercises and control of the underlying illness . The medical intervention suggested for this patient in order to establish rehydration and return calcium levels to normal is also supported within the research as well: onset of action for saline, calcitonin and bisphosphonate is 4 to 6 hours and 24 to 72 hours, respectively. Accordingly calcium excretion initiates at first hours of treatment and maximizes during 72 hours after starting of treatment. The duration of action of bisphosphonates is as long as 2 to 4 weeks