Raised Calcium, Thirst and Urinary Frequency — Free SCA Practice Case
Post-menopausal woman with raised calcium, thirst and urinary frequency
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Materials for Candidate
Please review before starting the consultation
Full Name
Patricia Nolan
Age
52 years
Consultation Type
TelephoneAge
52
Situation
Telephone Consultation. Booked to discuss recent blood tests done for thirst and urinary frequency.
Reason for Encounter
"I've been really thirsty and going to the loo a lot, so I had some bloods. I'm worried it's the start of diabetes — my mum had it."
Medical Records
- ●PMH: Post-menopausal (periods stopped ~2 years ago). Otherwise well.
- ●Medications: None. (No thiazide, no calcium/vitamin D supplements.)
- ●Allergies: NKDA.
- ●Recent results: Adjusted calcium 2.80 mmol/L (raised; ref ~2.20–2.60). HbA1c normal. Glucose normal. U&E/eGFR normal. (PTH and vitamin D not yet done.)
Patient Script
For the friend playing the patient role
Character Overview: You are Patricia, a 52-year-old office manager, post-menopausal. You have had increased thirst and urinary frequency for a few weeks and assumed it was the start of diabetes, as your mother had type 2 diabetes. You feel otherwise well. You are health-aware and a little anxious. You will be surprised to hear the issue is your calcium rather than your sugar.
Opening Sentence: "Hi Doctor. I've been really thirsty and needing the toilet much more than usual for a few weeks, so I asked for some blood tests. I'm worried it's the beginning of diabetes — my mum was diabetic. Can you tell me what they showed?"
History if Asked (Data Gathering Phase)
- ●The symptoms: "Thirsty all the time, drinking loads, and up in the night to wee. It's been a few weeks. That's why I thought diabetes."
- ●What she expected: "I was sure it'd be my sugar. I've been reading about pre-diabetes."
- ●Constitutional symptoms: "No, I feel generally well otherwise — no weight loss, no fevers, no lumps."
- ●Bones/abdomen/mood (only if asked): "No bone or joint pains. No tummy pain. My mood's fine, maybe a bit more tired. No constipation."
- ●Diet/supplements: "I don't take any calcium or vitamin tablets. My diet's reasonable."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.
- ●Ideas: Patricia is convinced her symptoms are pre-diabetes/diabetes, given her mother's history. "In my head this is my sugar — pre-diabetes, like my mum."
- ●Concerns: She is worried about developing diabetes and its consequences; learning it is a calcium problem will be unexpected and a little frightening. "I've been worried about diabetes. If it's not that — what does a high calcium mean? Is that serious?"
- ●Expectations: She expects to be told about her blood sugar and what to do about pre-diabetes. "I thought you'd tell me about my sugar levels and how to avoid diabetes."
If Asked — Hypercalcaemia Symptom and Cause Screen
The patient answers these only when directly asked.
- ●If asked about thirst and polyuria: "Yes — very thirsty and weeing a lot; that's my main problem." (Symptoms of hypercalcaemia, which she attributes to diabetes.)
- ●If asked about bone pain, fractures, or osteoporosis: "No bone pain, no fractures. I don't know my bone density."
- ●If asked about abdominal pain, constipation, nausea, or kidney stones: "No tummy pain, no constipation, no history of kidney stones."
- ●If asked about mood, low energy, or cognitive symptoms ('moans'): "A bit tired, but my mood's okay, thinking's clear."
- ●If asked about weight loss, night sweats, lumps (malignancy screen): "No weight loss, no night sweats, no lumps — I feel well otherwise."
- ●If asked about calcium/vitamin D supplements or thiazide diuretics: "No, I don't take any of those."
- ●If asked about family history: "My mum had type 2 diabetes. No one's mentioned calcium or parathyroid problems."
Responses to Management (The Negotiation Phase)
- ●If the Doctor explains it is her calcium, not her sugar: "So it's not diabetes? It's my calcium that's high? I wasn't expecting that." (The tested point is explaining the actual finding and correcting her assumption clearly.)
- ●If the Doctor explains the need to check PTH and vitamin D: "Why do you need more blood tests? What are you looking for?" (The tested point is the PTH-led work-up to find the cause.)
- ●If the Doctor raises primary hyperparathyroidism: "Overactive parathyroid glands? I've never heard of them. Is it dangerous? Is it cancer?" (The tested point is explaining likely primary hyperparathyroidism reassuringly and accurately, while excluding sinister causes.)
- ●If the Doctor advises on hydration and safety-netting: "Is there anything I should do in the meantime? Should I drink more or less?"
- ●If the Doctor discusses referral: "Will I need to see a specialist?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Hypercalcaemia — Recognise the Symptoms
- ●Hypercalcaemia causes "bones, stones, abdominal moans, and psychic groans" — bone pain, renal stones, abdominal pain/constipation/nausea, and mood/cognitive changes — plus polyuria and polydipsia (which patients, as here, may mistake for diabetes).
- ●Always use the adjusted (corrected) calcium.
The PTH-Led Work-Up
- ●The key investigation is parathyroid hormone (PTH) (with vitamin D and a confirmatory calcium):
- ●PTH raised or inappropriately normal with a high calcium → primary hyperparathyroidism.
- ●PTH suppressed → non-parathyroid cause (most importantly malignancy; also sarcoidosis, myeloma, vitamin D toxicity, etc.).
The Two Commonest Causes
- ●The two commonest causes of hypercalcaemia are primary hyperparathyroidism (common in post-menopausal women, usually a benign parathyroid adenoma) and malignancy — always screen for malignancy red flags.
Exclude Drug Causes
- ●Thiazide diuretics and calcium/vitamin D supplements are common contributors — check and stop where relevant.
Judging Urgency
- ●Mild-to-moderate hypercalcaemia in a well patient can be investigated in the community with routine/soon referral. Severe hypercalcaemia or an acutely unwell patient (vomiting, confusion, marked dehydration) requires urgent/same-day assessment for IV fluids and inpatient management.
Interim Management and Complication Assessment
- ●Advise good hydration and avoiding agents that raise calcium. Assess renal function, renal stones, and bone health (DXA) as part of the work-up.
Referral
- ●Refer to endocrinology for confirmation and management of primary hyperparathyroidism (including assessment of complications and the need for parathyroid surgery), with urgency matched to severity.
Common Candidate Mistakes in This Case
- ●Pursuing diabetes: anchoring on the patient's assumption and missing that the abnormality is the calcium.
- ●Not doing the PTH-led work-up: failing to order/interpret PTH and vitamin D.
- ●Not excluding malignancy: overlooking the second major cause of hypercalcaemia.
- ●Misjudging urgency: over- or under-reacting relative to the severity.
- ●Poor explanation/reassurance: leaving her confused about an unfamiliar diagnosis or with an unaddressed cancer fear.