Margaret English
Age: 62 years old female
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask history from head to toe
- Ask if the patient feels muddled, confused, or drowsy
- Ask about nausea or vomiting
- Ask about increased thirst (polydipsia) or increased fluid intake
- Ask about palpitations or chest pain
- Ask about tummy pain or constipation
- Ask about urinary frequency or blood in urine
- Ask about weight loss or reduced appetite
- Ask if they’ve noticed any new breast lumps or lumps in the armpits (given breast cancer history)
- Ask about bone pain (suggestive of bony metastases)
- Ask if they take any over-the-counter medications, especially vitamin D supplements
- Ask about smoking or alcohol intake
- Explore ICE (ideas, concerns, expectations)
- Ask about their home situation and support system
- Based on her symptoms and blood picture, you can form a working diagnosis of hypercalcaemia, likely secondary to recurrence of breast cancer
Example of explanation to patient
Mrs. English, thank you for coming in today, and I really appreciate you taking the time to have those blood tests — I know you’ve been feeling very tired and noticed some weight loss recently, so it’s good that we’re looking into things properly.
I’ve reviewed your blood results, and most of them are reassuring — your blood counts, liver and kidney function, and thyroid levels are all normal. However, one result has come back slightly out of range — your calcium level is a bit higher than normal.
There are a few possible reasons this could happen. In some people, the parathyroid glands in the neck can become overactive, and in others, it can be linked to medications like vitamin D supplements, especially if taken in high doses — but from what you’ve said, your vitamin D dose is quite low, so it’s unlikely to be the cause on its own.
Given your medical history, I am concerned that your high calcium could mean something more serious… pause …By serious, I mean that there is a possibility that your cancer may have returned. Now, I don’t want to alarm you, and this isn’t a definite diagnosis, but I do think it’s important we act quickly and get you checked by the breast team.
I’d like to refer you urgently to the breast clinic to be seen within the next two weeks. They’ll likely do a physical examination and may arrange scans to look more closely. This is a standard process we follow to make sure we’re not missing anything serious.
In the meantime, I’d advise you to stop taking your vitamin D tablets, just to be cautious. You can continue to eat normal calcium-rich foods like yoghurt and milk — they don’t usually cause calcium levels to rise to this extent.
I’d also like to arrange another blood test to check your parathyroid hormone levels and vitamin D, just to give us a better picture of what’s going on.
If you feel more tired, confused, nauseous, or notice any changes like constipation or more frequent urination, please let us know or call 111, as those can be signs that calcium levels are getting too high.
Lastly, if you don’t hear from the breast clinic within 2 weeks, please contact us straight away so we can chase it up.
How are you feeling about all that so far? Would you like me to write any of this down for you?
Management
- This is a mild case of hypercalcaemia, and since she has no significant symptoms, there is no need for hospital admission.
- Offer Face –to -Face to examine breast /armpit.
- Offer referral 2WW to breast clinic—Immediately safety net, advising if she does not hear from them in 2 weeks, to contact the surgery
- Offer further blood test for PTH and vitamin D
- Advise patient to drink fluids
- Advise patient that she can continue to take milk, yoghurts etc. The calcium in diet is unlikely to harm her
- As regards the vitamin D supplements—please stop this for now
- Safety net on worsening symptoms of hypercalcaemia
Learning point from this station:
This station highlights how to sensitively manage uncertainty and potential red flags in a patient with a history of breast cancer.
In patients with a history of cancer, new non-specific symptoms such as fatigue and weight loss, when accompanied by abnormal findings like hypercalcaemia, should prompt the clinician to consider the possibility of recurrence.
While mildly elevated calcium on its own may not always warrant urgent referral, in the context of a prior malignancy such as breast cancer, it should lead to thoughtful risk assessment and appropriate escalation. The clinician must balance reassurance with vigilance, ensuring timely investigation while supporting the patient through uncertainty.