Old Records

Got a semi-urgent consult, a man with a calcium of 11.9.  He was asymptomatic but what made it urgent was the desire to send him to a rehab facility the next day.  Not being otherwise engaged, I went up to see him, having read the current chart from my desk.  As I got to the charting room, some brand new interns, first week, were milling around, already discussing discharges with each other to the neglect of incomplete medical care.  One of them owned up to having been assigned this fellow who just had his hyperparathyroidism confirmed by the lab.  So the questions were obvious to me:  what was his previous calcium?  Did he have urolithiasis?  Did he ever fracture anything?  Why was he on Casoex?  They looked at the lab work, called me, took no relevant history, did not seek out records, and plotted his exit at the earliest possible time.  Not a good way to imprint the expectations of medical care on medical newbies.

I called the young'un over.  We opened the chart from the other campus of our medical center, about a five minute effort.  He had been hospitalized the previous year.  His calcium was consistently 10.6-11.0.  No testing was done, though he did have an abdominal CT which showed no renal stones at the time.  There was a lab result from six months ago, calcium 11.0 so it is clearly rising.  He had a medicine list.  hctz on it, though stopped here.  Also leupron on it so now it is clear why he also took Casodex.  Renal function normal, then and now. 

Haven't even entered this fellow's room and it was clear he had hyperparathyroidism with a rising calcium and he also had prostate carcinoma that was being treated medically.

Interviewing him did not add a whole lot.  He could tell me who was prescribing the prostate treatment.  He did not have stones, moans, groans, or psychic overtones.  He had also not been told of the calcium elevation before.  And his bp was pretty high, presumably some of it from stopping the hctz.

So he would benefit from a parathyroidectomy and from some revisions in his antihypertensives.

And the new trainees need to redirect their focus away from discharge to more thorough care while the patient is their responsibility.