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This case depicts an elevated total calcium with apparently normal ionized calcium. First, is the total calcium level expected to be elevated due to a high albumin concentration ? (unlikely). Secondly, the ionized calcium level in an acutely ill patient should be interpretted with the pH of the sample. ((For example, an ionized calcium level of 1.15 mmol/L can be obtained in serum which has a high total calcium and is alkalotic )). The third facor I would consider is: How was the ionized calcium specimen collected (any anticoagulant ? any delay in analyses?). That would be my trouble-shooting approach. regards, Andrew