An 82-year old man, seeing his Family Doctor. Clinical information is
'haematuria'. Serum results are
Sodium: 141 mmol/L
Potassium: 4.6 mmol/L
Urea: 4.4 mmol/L
Creatinine: 77 umol/L
Albumin: 40 g/L
Corrected calcium: 2.71 mmol/L (2.10 - 2.55)
Alkaline phosphatase: 68 IU/L (<126)
AST: 19 IU/L (<41)
ALT: 29 IU/L (<56)
PSA: 10.8 mg/L (<4)
Sorry for the mistake in PSA units - they should have been ug/L (of
course!)
This Case attracted 30 human and 1 electronic participants.
8 would talk to the FD; [0.8]
2 would not phone the FD (one predicting that this would score -2). [-0.5]
11 felt that referral for urologist review was appropriate.[1.3]
8 commented '(mildly) elevated PSA - BPH, prostatitis, or CA?' [0.8]
3 commented 'mildly elevated PSA - significance uncertain' [0.5]
6 suggested a DRE/ clinical review of prostate; [0.8]
1 each queried
a Digital Rectal Examination before the sample was taken. [0]
UTI. [0*]
With regard to the mild hypercalcamia
3 queried a drug effect [-0.3]
With regard to the combination of findings
6 queried the possibility of CA prostate with secondaries; [0.8]
3 queried the possibility of a renal calculus; [0]
2 mentioned the normal alkaline phosphatase probably suggested other causes
[not CA prostate] for the raised calcium; [0.8]
2 urged caution in linking the elevated calcium with the elevated PSA.
[1.5]
11 would check PTH; [1.0]
8 would repeat the calcium; [1.3]
5 would measure serum phosphate; [1.0]
3 would ask for a repeat sample for free/ total PSA; [1.3]
1 each would measure
24-hour urine calcium, phosphate, and oxalate; [0]
serum protein electrophoresis and urine Bence-Jones protein; [1.3]
a repeat total PSA; [1.3]
total acid phosphatase; [-2.0]
urine microscopy; [0.8]
urine haemoglobin. [0.3].
The electronic participant commented
'The population risk for CA prostate is 7% at PSA > 4 and 28% at PSA > 10
ug/L. Specialist urological opinion is recommended at PSA > 10 mg/L'.
Its human owner added 'slightly raised calcium - ?related to raised PSA'.
I wondered what best to do about this suggestive combination of clinical
findings and biochemical abnormalities. Had the patient been younger, I
would probably have telephoned; but here I did not, and restricted myself
to the cautious comment (the first sentence being computer-generated):
'Raised PSA - prostatitis?; BPH?; neoplasia??. Cause of elevated calcium?
Best wishes
Gordon Challand
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