A patient with severe hypercalcemia symptoms and dehydration. Immediate management includes:

• A. Aggressive IV fluids and evaluation for underlying cause
• B. Calcitonin infusion
• C. Diuresis with loop diuretics only
• D. Ketoconazole

Answer: (A)

The key idea is that volume repletion is the first priority in severe hypercalcemia with dehydration. Giving aggressive intravenous isotonic saline restores intravascular volume, improves renal perfusion, increases the glomerular filtration rate, and promotes calcium excretion in the urine. This not only helps lower the calcium level but also stabilizes the patient enough to pursue a full workup for the underlying cause, whether it’s hyperparathyroidism, malignancy, vitamin D–mediated processes, or another source. After fluids, additional treatments can be added as needed (for example, calcitonin for rapid but short-term reduction, and bisphosphonates for longer-term control), but they do not replace the need to first correct dehydration. Diuresis with loop diuretics alone is not appropriate initially because it can worsen dehydration and kidney function, and ketoconazole is not part of the immediate management strategy for hypercalcemia.