Consultation note
Time in:
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Patient Name:
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Dr. ___________ has asked for consultation on this patient regarding regarding _______________.

Thank you for inviting us to see this patient.

Chief complaint: ___ year old male/female presents today for evaluation and treatment of hyperparathyroidism.
Patient denies/admits to radiation to head and neck

Patient denies/admits to family history of hyperparathyroidism or multiple endocrine neoplasia (MEN1 2a)

Patient denies/admits to peptic ulcer disease

Patient denies/admits to depression, decreased mentation, coma, weakness, nausea, anorexia, vomiting, abdominal pain, constipation, polyuria, easy fatiguability, bone pain, fractures, lethargy, •  less commonly arthralgias, proximal myopathy, paresthesias, weight loss,   personality disorder or psychosis relatively uncommon, recurrent urinary tract infection (UTI), thiazide diuretics may uncover latent disease by decreasing renal calcium excretion, 10% prior history of neck irradiation for Hodgkin's or radioactive iodine for hyperthyroidism, fatigue, daytime sleepiness, muscle weakness and lack of emotional and sexual interest

My key findings of the ROS, Past Hx, Family Hx, and social Hx are:
ROS: Review of 12 systems was negative with exception of those things mentioned above in the HPI and weightloss/weight gain, headache, fever, chills, heat/cold intolerance, chest pain, dyspnea, cough, sinus/allergy complaints, frequent infections, nausea, vomiting, diarrhea, constipation, erectile dysfunction, genitourinary complaints, muscle aches or pains, numbness or tingling, easy bruisability or bleeding, hair changes/alopecia, skin changes/ulcers, tremors, depression or anxiety.

Patient denies weightloss/weight gain, headache, fever, chills, heat/cold intolerance, chest pain, dyspnea, cough, sinus/allergy complaints, frequent infections, nausea, vomiting, diarrhea, constipation, erectile dysfunction, genitourinary complaints, muscle aches or pains, numbness or tingling, easy bruisability or bleeding, hair changes/alopecia, skin changes/ulcers, tremors, depression or anxiety.

Past Medical History:

Past Surgical History:

Family History:

Social History:
Diet:
Exercise:
Smoking:
Recreational Drug use :
Education:
Occupation:
Lives with ____ where ____

Home Meds:

Allergies:

My key findings of this patient's Physical Exam are:
VITALS:
Pulse:
Blood Pressure:
Respirations:
Temperature:
Weight:
Height:
BMI:

GENERAL: sitting up/reclined in bed, awake, alert, and oriented, hypertension, kyphosis
HEAD: normocephalic, atraumatic, no temporal wasting, negative chvostek sign
NOSE, MOUTH: lips and mucous membranes are moist, normal color of buccal mucosa
EYES: EOMI, PERLA, no proptosis, band keratopathy
NECK: supple, thyroid normal in size, thyroid small, thyroid low set, no thyromegaly or masses, palpable parathyroids
RESPIRATORY: clear to ascultation bilaterally
CARDIOVASULAR: S1S2, no murmurs/rubs/gallops
GI: soft, non-tender, + bowel sounds
LYMPHATIC: no cervicoclavicular adenopathy appreciated
MUSCULOSKELETAL: moving all extremities
EXTREMITIES: no edema present, atrophy of proximal muscles
NEUROLOGIC: monofilament sensed in all areas of the foot, vibratory sensation intact, fine/crude touch intact, pulses palpable, DTRs 2+, CN grossly intact
DERMATOLOGY: no xanthomas appreciated, no skin ulcers, no calluses, no onchyomycosis/dermatophyosis, no striae,
PSYCHIATRY: patient answers questions appropriately, appropriate affectcoherent thoughts without flight of ideas

Labs:
Na
K
Cl
CO2
BUN
Creat
Gluc
Ca
Mg
Phos
WBC
Hgb
PCV
Plt
SGOT
SGPT
GGT
Alb
TBil
AlkP
CPK
CKMB
TropnT

Bone and Mineral
Intact PTH:
Ionized Calcium:
Ca:
Mg:
Phosphorus:
25-OH Vitamin D:
1,25-OH Vitamin D:

Thyroid:
TSH:
FT4:
TT4:
QT3:
Athyp:
AthyG:
Calcitonin:
Thyroglobulin:

Assessment:

Primary hyperparathyroidism associated with greatly increased risk for renal stones, only partially reduced after surgery

Types:

Primary hyperparathyroidism -

Secondary hyperparathyroidism - decreased calcium, increased parathyroid hormone (PTH), causes - chronic renal failure, hypophosphatemia, decreased vitamin D, hypomagnesemia, complications - bone disease (osteitis fibrosa), metastatic calcification, accelerated vascular calcification, occasionally severe pruritus and painful skin ulcers, •  treatment - dialysis with high calcium bath, phosphate-binding antacids, calcium supplementation and active vitamin D, subtotal parathyroidectomy if refractory, doxercalciferol (Hectorol) is vitamin D analogue FDA approved to reduce elevated iPTH levels in secondary hyperparathyroidism in patients undergoing chronic renal dialysis, available in 2.5 mcg capsules, initially 10 mcg 3 times per week then titrated based on iPTH levels, calcitriol (Rocaltrol) 0.25-2 mcg by mouth daily and paricalcitol (Zemplar) 0.04-0.1 mcg/kg intravenously 3 times weekly with dialysis may be used instead of doxercalciferol.

Tertiary hyperparathyroidism - due to long-standing hyperplasia, increased calcium, which may persist despite renal transplant, decreased phosphate, hypercalciuria, same symptoms as secondary hyperparathyroidism, treatment - subtotal parathyroidectomy if persistent

80-90% parathyroid adenoma - benign, usually singly in parathyroid gland (0.4% multiple adenomas), 8-20% parathyroid hyperplasia especially in multiple endocrine neoplasia (MEN) - diffuse enlargement of all 4 glands, less than 0.5% parathyroid carcinoma - metastases to nodes, rare - parathyroid cyst, squamous cell lung cancer or renal cell carcinoma - PTH-like hormone, familial isolated hyperparathyroidism - genetically heterogeneous, hyperparathyroidism-jaw tumor syndrome - very rare, autosomal dominant, predisposes to ossifying fibromoma of mandible and maxilla and parathyroid carcinoma

Diagnostic Plans:
Elevated intact parathyroid hormone (iPTH) level in setting of hypercalcemia and/or hypercalciuria. Rule out: hypocalcemia, hypomagnesemia, PTH-related peptide, familial hypocalciuric hypercalcemia, post-renal transplant, tumor-related bone disease, multiple myeloma, sarcoidosis, thiazides, milk-alkali syndrome, hypervitaminosis A or D,   thyrotoxicosis, Addisons disease

Tests: calcium level, repeated in a repeat serum calcium, especially important to observe proper drawing conditions, 50% of mildly elevated calcium results caused by preanalytical factors and not by disease, intact parathyroid hormone, other blood tests include creatinine, chloride, phosphorus, bicarbonate, magnesium, alkaline phosphatase (AP), 1,25 vitamin D, ESR, CBC, spot fasting urine calcium/creatinine ratio, also consider serum protein electrophoresis (SPEP), PTH-related peptide, ultrasonography and isotope scans occasionally helpful for diagnosis in children, bone densitometry (DEXA bone density of hip and spine)

Blood tests:  increased PTH, Ca, Cl, AP, 1,25 vitamin D, (occasionally) ESR, decreased PO4, HCO3-, Mg++, hyperchloremic acidosis, mild anemia, Cl/PO4 ratio > 33, monoclonal gammopathy present in 10% of 101 patients with primary hyperparathyroidism (including 2 with multiple myeloma) and only 2-3% controls undergoing other surgery or with benign thyroid diseases ( Arch Intern Med 2002 Feb 25;162(4):464 )

Urine studies: excess urine excretion of calcium (decreased then increased, increased on Ca-restricted diet), decreased tubular reabsorption of phosphorus < 50% , (hyperphosphaturia),  increased urinary cAMP

Imaging studies:  for re-exploration MRI and CT (including mediastinum) - not accurate, expensive, ultrasound useful in 70-80%, 99Tc-labeled Sestamibi with SPECT imaging may detect up to 85% of adenomas, most widely used imaging technique, dual-tracer imaging (thallium-technetium scan) useful in 70-80%, 201-Tl lights up thyroid and parathyroid. 99m-Tc lights up thyroid. X-rays may show demineralization of bone (common) or uncommonly subperiosteal resorption (middle phalanges and tufts of terminal phalanges), osteopenia (phalanges, skull with "ground-glass" outer 2/3, distal clavicle), salt and pepper skull (check sella turcica for MEN), reabsorption of proximal end of long bones, osteosclerosis, nephrocalcinosis, pancreatic calcifications, chondrocalcinosis, soft tissue calcifications, osteitis fibrosa cystica (usually in secondary and tertiary hyperparathyroidism, brown tumor [osteolytic], von Recklinghausen's disease of bone, fibrous replacement), demineralization of bone, abdominal ultrasound may reveal , evidence of stones or nephrocalcinosis,   preoperative technetium Tc-99m sestamibi SPECT imaging in patients with conomitant multinodular goiter allowed for minimally invasive radioguided parathyroidectomy in 21 (51%) of 41 such patients ( Arch Surg 2005 Jul;140(7):656 in JAMA 2005 Sep 7;294(9):1016)

Therapeutic Plans:

in primary hyperparathyroidism, parathyroidectomy curative and appears especially useful in symptomatic patients in uncontrolled study

Surgery indications:

•  calcium > 1 mg/dL (0.25 mmol/L) greater than upper limit for lab used

•  24-hour urine calcium > 400 mg

•  bone disease

•  nephrolithiasis or urolithiasis

•  renal failure (creatinine clearance < 30% of age/sex-matched controls)

•  bone density at lumbar spine, hip or distal radius > 2.5 standard deviations below peak bone mass (T score)

•  age < 50 years old

Subtotal parathyroidectomy recommended as adequate treatment for primary hyperparathyroidism in multiple endocrine neoplasia type 1

Patient Education:
Often transient hypocalcemia following successful parathyroidectomy

Annual DEXA bone density

Family screening may be warranted in familial syndromes

Consider screening for multiple endocrine neoplasia in patients with surgical failure

Vitamin D to patients with renal failure

Return to Clinic:
We have discussed our diagnostic and treatment plans with the patients and family/friends that were present. All questions have been answered to the patient's satisfaction.

Thank you for inviting to see this consult!

Written by ___ _____________________ Time out_______

•  252.0 hyperparathyroidism

•  252.00 hyperparathyroidism, unspecified

•  252.01 primary hyperparathyroidism

•  252.02 secondary hyperparathyroidism, non-renal

•  252.08 other hyperparathyroidism

•  588.81 secondary hyperparathyroidism (of renal origin)

•  194.1 malignant neoplasm of parathyroid gland

•  259.3 ectopic hormone secretion, not elsewhere classified

•  713.0 arthropathy associated with other endocrine and metabolic disorders