Q. A nurse calls you to ask you about a patients low calcium level. He is concerned about a patient on your service, specifically a 45 year-old alcoholic man who was admitted after being found drunk and stuporous in the street. The patient’s mental status has improved with restarting his lactulose and discharge is planned for this afternoon. His B/P is currently 146/82 mmHg, his temperature is 98.6 F, and respirations are 22/min. The patient is alert and oriented and does not seem to be in any distress. Physical exam reveals temporal wasting, numerous spider angiomas, mild gynecomastia and marked hepatosplenomegaly. The physical finding of shifting dullness and 2+ pitting edema bilaterally are also present. The nurse is concerned because the patients total calcium level is 7.0 mg/dL, and he wants to know what to do. Which is the most appropriate management at this time?
A. Administer vitamin D supplementation
B. Check the EKG for any dysrhythmias
C. Administer calcium carbonate, 1-2 g/day
D. Administer calcium gluconate 200mg (a ampules) stat
E. Check albumin
F. Check magnesium level
G. Preform a mini-mental status exam
H. Check for Chvostek sign
The correct answer is E. Check albumin level
The patient’s hypocalcemia is likely factitious. Given by the obvious advanced liver disease, a quick review of this patient’s recent liver function tests will likely reveal a low albumin. Calcium in the bloodstream exists as bound (mainly to albumin) and free (or ionized) calcium, the latter of which is physiologically important. As albumin levels decrease, common in advanced liver disease, total calcium also decreases; however ionized calcium remains constant. An ionized calcium level can be checked or a simple adjustment for the reduced albumin can be made… NOTE: for every 1 g reduction in albumin below 4 g/L (normal), total calcium levels will decrease 0.8 mg/dL. For example, if this patient’s albumin were 2 g/L, the calcium level would be 8.6 (7.0 + adjustment of 1.6), which is within the normal range and does not require treatment.