Question of the Day
Tuesday, November 3, 2026
A 66-year-old man with multiple myeloma is brought to the emergency department because of nausea, confusion, and worsening constipation for 3 days. He has been taking little by mouth. His temperature is 37.2°C (99.0°F), pulse is 104/min, respirations are 18/min, and blood pressure is 108/64 mm Hg. Physical examination shows dry mucous membranes and lethargy. Laboratory studies show calcium of 14.6 mg/dL, creatinine of 2.0 mg/dL, and albumin of 3.6 g/dL. Electrocardiography shows a shortened QT interval.
Which of the following is the most appropriate initial step in management?
Answer: B. Intravenous normal saline
This patient has a symptomatic hypercalcemic emergency (calcium 14.6 mg/dL with confusion, volume depletion, and ECG changes) from myeloma. The first and most important step is aggressive volume repletion with intravenous isotonic saline, which restores intravascular volume and promotes renal calcium excretion. Calcitonin (E) works quickly and is a useful adjunct but is given together with, and after, fluids, and its effect is modest and short-lived due to tachyphylaxis. Zoledronic acid (C) produces durable lowering but takes 2-4 days for full effect and dosing must account for renal function, so it is not the immediate first move. Hemodialysis (A) is reserved for severe hypercalcemia with renal failure or when fluids are contraindicated. Oral phosphate (D) is slow, poorly tolerated, and risks metastatic calcification. The teaching point is that isotonic saline resuscitation is the initial treatment of acute hypercalcemia, with bisphosphonates and calcitonin added for sustained and rapid control.
Just show me the answer
Answer: B. Intravenous normal saline
This patient has a symptomatic hypercalcemic emergency (calcium 14.6 mg/dL with confusion, volume depletion, and ECG changes) from myeloma. The first and most important step is aggressive volume repletion with intravenous isotonic saline, which restores intravascular volume and promotes renal calcium excretion. Calcitonin (E) works quickly and is a useful adjunct but is given together with, and after, fluids, and its effect is modest and short-lived due to tachyphylaxis. Zoledronic acid (C) produces durable lowering but takes 2-4 days for full effect and dosing must account for renal function, so it is not the immediate first move. Hemodialysis (A) is reserved for severe hypercalcemia with renal failure or when fluids are contraindicated. Oral phosphate (D) is slow, poorly tolerated, and risks metastatic calcification. The teaching point is that isotonic saline resuscitation is the initial treatment of acute hypercalcemia, with bisphosphonates and calcitonin added for sustained and rapid control.
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