Hypercalcemia

1
Hypercalcemia Primary Hyperparathyroidism

• Stacey DonFrancesco, MS III
• PCOM Grand Rounds
• 8/4/2009

2

• HPI 23 year old female presented to Frankford
  ER on 4/22/09 from Friends Hospital for
  overdose. Patient admitted to taking 8- 80 mg
  Oxycontin and 4- 4 mg Xanax in an attempt to kill
  herself. She suffers from depression and admitted
  to multiple other suicide attempts in the past.
• Meds Denies
• Allergies NKDA
• PMHx Multiple suicide attempts, anxiety,
  depression, bipolar disorder
• PSHx None

3

• FamHx Non-contributory
• SocHx () Tobacco ETOH use, denies illicit
  drug use
• PE
• VS Temp 98.4, BP 140/82, HR 99, RR 20, Wt 60.3
  kg
• General well nourished, NAD
• Eyes PERRLA, EOMI
• Neck Supple, NT, (-) thyromegaly, nonpalpable
  mass
• Lungs CTA B/L, no wheezing/rales/rhonchi
• Heart () S1, S2 RRR
• Abdomen () BS, soft w/ mild suprapubic
  tenderness, (-) rebound/guarding
• Extremities (-) edema
• Neuro motor sensory intact
• Mental status AAO x 3 , normal affect

4
Labs 4/23/09

• CBC
• WBC - 6.3
• Plt Count 182
• Hgb 15.6, Hct 44.4
• CMP
• Na 136, K 4.1
• Cl- 104, CO2 25
• BUN 11, Creat 0.78
• Glucose 87
• Ca2 12.0

• Other
• PTH 119.2
• Pregnancy Test (-)

5
Imaging

• Parathyroid Imaging Technetium - 99 Sestamibi
  Radionuclear Scan - 4/24/2009
• - Results Findings consistent with functioning
  adenoma overlying lower pole of (R) lobe of
  thyroid

6
Technetium-99 labeled Sestamibi Scan
7
Technetium-99 labeled Sestamibi Scan
8
Imaging

• Ultrasound of Thyroid 4/27/2009
• - Results Complex cystic mass adjacent to right
  lobe of thyroid which may represent a parathyroid
  adenoma

9
Ultrasound of Thyroid
10
Ultrasound of Thyroid
11
Pre-Op Labs 7/8/09

• CBC
• WBC 8.2
• Plt Count 184
• Hgb 13.9, Hct 39.3
• CMP
• Na 139, K 4.1
• Cl- 107, CO2 27
• BUN 9, Creat 0.99
• Glucose 79

• Ca2 - 11.3
• PTH 164.3

12
Surgical Rx - Parathyroidectomy

• Transverse incision was made overlying thyroid
  isthmus with initial division of platysma
• Strap muscles were retracted laterally, middle
  thyroid vein was identified, ligated, and tied
  off.
• Right inferior lobe parathyroidectomy was
  performed with removal of parathyroid adenoma
• Adenoma was sent to pathology for confirmation of
  complete removal before closing

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Operative Note

• Preop Diagnosis Hyperparathyroidism
• Postop Diagnosis Hyperparathryoidism 2 to
  parathyroid adenoma
• Procedure Right Inferior Lobe Parathyroidectomy
• Anesthesia GETA
• EBL 5 mL
• Fluids 1200 mL
• Specimen Right inferior parathyroid gland
• Drains None
• Complications None
• Condition Stable

14
Post-Op Labs 7/17/09

• Ca2 - 9.7
• PTH 12.5
• Mg 2.2
• VS - Stable
• - 98 98/58 55 20

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Post-Op Course

• POD 1
• Labs
• Ca2 8.7
• Mg 1.9
• PE no hoarseness or dysphagia
• Started on clear liquid diet
• POD 2
• Patient did well, tolerated regular diet
• Discharged on calcium supplements
• Pathology report demonstrated parathyroid adenoma