Dear all, I wish to share an interesting and uncommon case of hypercalcemic crisis with calcium levels of 16. I was called for a home visit of a 75 year old female patient from mulund west for complaints of joint stiffness, difficulty in walking and vomiting. Past history: She had a history of diabetes mellitus for 3 yrs on oral hypoglemics, anemia and hypothyroidism since 2 months on treatment. She had a history of d12 fracture in 2018 treated conservatively at fortis and given 2 high strength calcium supplements since then. Her follow up with ortho specialist was not proper and she was on very high dose calcium supplements from 2018 till 2023 without any monitoring when she presented to me. Current symptoms and findings: On visiting her for above complains I found a restriction in her ROM for both knees. She also had some dysuria. Her vitals were stable and no neurological deficits. I ordered a battery of tests including serum creatinine, electrolytes, calcium, uric acid and xray. To our surprise her calcium levels were 16 and creatinine of 2.2 and urine showing 60 pus cells and uric acid 8.6. Management: In view of such high calcium levels I got her admitted in an urgent basis at ICU. Her ecg showed ST elevation, shortened QT interval. Her trop I and d dimer were in normal range. Her wbc counts were raised due to UTI. After central line insertion we started hydration and lasix infusion. We gave her inj zolendronic acid 4mg/100 ml iv over 30min. Inj calcitonin 4IU/kg Sc given 12 hourly. Serum calcium and ionised calcium were monitored every 6 hourly till normal. Inj piptaz was given in renal dose for UTI. Febuxostat 40 mg was started for high uric acid levels. Other symptomatic medicines also given. Progress in ICU and then wards: Her calcium levels dropped over first 24 hours to 12 mg/dl and then to 10 mg/dl on second day. Ecg normalised on second day and then she was transferred from ICU to wards. Her symptoms of joint stiffness went away. Vomiting stopped. We also gave her parenteral iron correction for anemia. Serum parathormone levels were normal. Vit d3 levels were 120. Serum ACE levels were raised. Tumor marker work up to look up for a cause of secondary hypercalcemia was negative. CT chest was normal. No tumors and no findings of sarcoid. After 3 days stay in general ward her UTI was also corrected and then she was discharged to home. We added her on finerenone which is a non steroidal mineralo corticoid receptor antagonist. This is a new molecule launched in india for CKD patients to halt further worsening. It reduces drop in eGGR by 40% as per studies. The cause of hypercalcemia was unsupervised over calcium supplementation over period of 4 years along with failing kidneys. Status post discharge: Patient is now doing well at home with baseline creatinine of 1.7, controlled sugars. All calcium supplements are stopped for now and current calcium is 9.6 mg/ dl. She is on medicines for sugar, thyroid, ckd and anemia. Moral of story: 1) If you are giving high dose calcium supplementation for a fracture it must be given for a short time like 4 to 6 weeks with strict monitoring. 2) Regularly check for calcium and creatinine in such patients. 3) Finerenone is a new non steroidal mineralocorticod receptor antagonist which is proven to reduce drop of eGFR in CKD patients. Dr Hardik Thakker, MD MED, ECFMG (USA).