QuestionSBA
QuestionChoice
The patient's presentation is suggestive of hypercalcaemia caused by malignancy, which is likely leading to abdominal pain. There are no specific examination findings (e.g. right upper quadrant pain) mentioned that immediately warrant an ultrasound scan.
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d
Ultrasound abdomen
QuestionChoice
While brain metastases may account for the confusion and these may be seen on CT, the next best investigation would be a bone profile to check whether the symptoms are due to hypercalcaemia. A simple blood test is both quicker and easier than performing imaging.
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CT scan of the brain
QuestionChoice
A CT of the urinary tract is the investigation of choice for renal colic. There is no mention of flank pain or haematuria, making this diagnosis unlikely. Hypercalcemia should be investigated for with a bone profile.
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CT urinary tract (KUB)
QuestionChoice
The patient's symptoms of abdominal pain, thirst, and confusion are suggestive of hypercalcaemia due to her malignancy. A bone profile would confirm this.
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Bone profile
QuestionChoice
While brain metastases may account for the confusion and these may be seen on MRI, the next best investigation would be a bone profile to check whether the symptoms are due to hypercalcaemia.
10017377
b
MRI scan of the brain
QuestionComment
I mean kidney stone is a sign of hypercalcaemia and severe abdominal pain (when we aren't told where in the abdomen) could be an indication of a colicky picture so CT KUB sounds plausible here
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and if my grandma had wheels, she'd be a bike
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# Summary

Confusion is a common issue in oncology, with diverse causes including metabolic disturbances, infections, and metastatic spread to the brain. It is crucial to identify and treat underlying factors, as confusion can distress patients and families. Delirious patients face higher risks of falls and complications, requiring careful management strategies.


# Differentials of confusion in oncology

Confusion is a common presenting complaint within general medicine and oncology. Confusion seen in the context of a cancer patient alters the likelihood of certain causes of confusion.

There are a diverse range of causes for confusion in oncology patients:

- **Metabolic disturbance** (hypoglycaemia, hypercalcaemia): this may present acutely or subacutely. Patients often have concurrent symptoms such as feeling hungry or shaky for hypoglycaemia and very thirsty or GI upset for hypercalcaemia.
- **Neutropenic sepsis**: this is an oncological emergency and may be difficult to spot, as many usual signs of infection may be absent. In any patient with known or suspected neutropenia presenting with confusion, neutropenic sepsis should be top of the differential list.
- **Infection** (pneumonia, UTI): patients may have localising symptoms of infection. For example, a cough or dysuria. However patients may present atypically so always consider whether sepsis could be causing the confusion, even in the absence of typical signs.
- **Metastatic spread to the brain**: typically, this is subacute onset and associated with headache, visual disturbances and/or focal neurology. The most common cancers to spread to the brain are lung, breast, colorectal, melanoma and renal cell carcinoma. Therefore have a low threshold for suspecting metastases especially in these cancers.
- **Anaemia**: this may be difficult to diagnose clinically, as cancer and its treatment causes fatigue for most patients. A full blood count is a useful investigation to rule out anaemia and neutropenia.
- Other causes of delirium, including **pain, constipation and medications**. It is important to rule out these reversible causes of confusion. This can be elicited in the history and medication review, and treatment can make a significant difference to the patient's mental status and quality of life.

# Management

It is important to recognise and treat the underlying cause of confusion. This can be distressing for the patient and relatives alike.

Patients with delirium (acute confusional state) are at increased risk of falls, increased mortality and morbidity. Environmental modifications can help reduce confusion, as well as optimising reversible factors and falls risk reduction measures. Pharmacological management is reserved for when non-pharmacological measures do not work or when a patient is agitated towards the end of life.

# NICE guidelines

[NICE CKS: Delirium](https://cks.nice.org.uk/topics/delirium/)

# References

[Marie Curie: Delirium in palliative care](https://www.mariecurie.org.uk/professionals/palliative-care-knowledge-zone/symptom-control/delirium)
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Differentials of Confusion in oncology
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Oncology and Palliative Care
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In metastatic breast cancer, a bone profile, including calcium, phosphate, alkaline phosphatase (ALP), and albumin, is performed to assess bone involvement and detect complications such as bone metastases, hypercalcemia, or changes in bone density.
A 55-year-old woman with a background of metastatic breast cancer is admitted to hospital due to severe abdominal pain. She is being treated with hormonal therapy (letrozole) and her disease has been stable for the past few years.

She becomes increasingly confused and agitated on the ward. Her family also notice she has become more thirsty.

Which of the following is the next best investigation to perform?
a