tokens: 517414339 PUOMC 4351342 88500 099515 12/26/1996 12:00:00 AM HYPERPARATHYROIDISM . Unsigned DIS Report Status : Unsigned DISCHARGE SUMMARY NAME : HOUGHTJESCSLEM , RIESHINJIN R UNIT NUMBER : 948-14-32 ADMISSION DATE : 12/26/96 DISCHARGE DATE : 01/01/97 PRINCIPAL DIAGNOSIS : hyperparathyroidism . ASSOCIATED DIAGNOSIS : 1. status post mitral valve replacement , 2. hypertension , 3. atrial fibrillation , 4. hypertrophic obstructive cardiomyopathy , 5. osteoarthritis , 6. right cheek basal cell carcinoma , 7. glaucoma , 8. non-insulin dependent diabetes mellitus , 9. status post laparoscopic cholecystectomy , 10. status post dilation and curettage , 11. status post cataract surgery , 12. status post left breast biopsy . PRINCIPAL PROCEDURE : Parathyroidectomy on 12-27-96 . HISTORY OF PRESENT ILLNESS : The patient is an 83-year-old female who presents for surgical evaluation for her hyperparathyroidism . This is an 83-year-old female with a history of hypertrophic obstructive cardiomyopathy , status post mitral valve replacement in 1988 , chronic atrial fibrillation , hypertension , who presents for parathyroidectomy . In August of 1996 while the patient was at Retelk County Medical Center for replacement of her knees bilaterally , and on preoperative evaluation she was noted to have a high calcium and therefore the surgery was canceled . Further testing revealed hyperparathyroidism as evidenced by an elevated PTH . The patient reports no masses in her neck . She has noticed some generalized hoarseness in her voice for the past 5-6 months . In addition , she has some dysphagia , particularly has had some difficulties with swallowing . She has been seen by Dr. Tokbelb , her primary care physician in Itgreenredan Hospital , and also Dr. Kotefyfechird , her cardiologist , and also an endocrinologist at Retelk County Medical Center . PAST MEDICAL HISTORY : 1. status post mitral valve replacement in 1988 . She has a St. Jude &apos;s mechanical valve and has been on Coumadin since then , 2. hypertension , she has had hypertension for 15 years , 3. atrial fibrillation , she is status post cardioversion 3-25-94 , 4. hypertrophic obstructive cardiomyopathy , 5. osteoarthritis ; she is to receive bilateral total knee replacements at some time in the near future , 6. right cheek basal cell carcinoma to be removed in the future , 7. history of glaucoma , 8. non insulin dependent diabetes mellitus which was diagnosed in March , 1995 , 9. shingles . PAST SURGICAL HISTORY : 1. laparoscopic cholecystectomy 03/93 by Dr. Sapmal , 2. dilation and curettage in 1992 for polyps , 3. left breast biopsy which was benign , 4. cataract surgery . ALLERGIES : No known drug allergies . MEDICATIONS ON ADMISSION : 1. Lopid 600 mg PO b.i.d. , 2. K-Dur 20 mg PO q.day , 3. Lasix 40 mg PO q.day , 4. Coumadin 2.5 mg PO q.day which was last taken two days prior to admission , 5. Norvasc 500 mg PO q.day , 6. Digoxin .25 mg PO q.day , 7. Lopressor 50 mg PO b.i.d. , 8. Glucotrol 10 XL qam , 9. Timoptic 0.5% b.i.d. to both eyes , 10. Pilocarpine gel qhs to both eyes . FAMILY HISTORY : There is no family history of parathyroid or thyroid diseases . SOCIAL HISTORY : The patient is widowed . She lives alone but is completely independent . She visits her daughter once a week . No ethanol or tobacco use . REVIEW OF SYSTEMS : The review of systems is significant for a history of dyspnea on exertion . At present , she can walk one to two blocks before having to stop because of shortness of breath . When walking outside , she stops multiple times because of shortness of breath . She sleeps with two pillows at night . She gets short of breath walking up steps . PHYSICAL EXAMINATION : On physical examination , she is a pleasant woman in no acute distress . Her pulse is 72 , irregularly irregular , blood pressure 96/60 , temperature 97.9 , respirations 18 . The head , eyes , ears , nose and throat examination is notable for pupils which have irregular border and are very sluggishly reactive . The patient reports that she will have revision of cataract surgery . Neck and lungs are unremarkable . Cardiovascular exam : III / VI systolic click and irregularly irregular rhythm . The abdomen was benign . She is guaiac negative on rectal examination . Extremities : unremarkable . LABORATORY DATA : Admission white blood count 4.3 , hematocrit 31.0 , electrolytes were all within normal limits , glucose 218 , prothrombin time on admission was 15.1 with INR of 1.5 , partial thromboplastin time 23.3 . The electrocardiogram showed atrial fibrillation with slow ventricular response and digitalis effect as well as left ventricular hypertrophy . IMPRESSION ON ADMISSION : Impression was that this was an 83-year-old female with cardiac history , dyspnea on exertion , increased calcium and hyperparathyroidism who presents for parathyroidectomy . HOSPITAL COURSE AND TREATMENT : On the day of admission , the patient was brought to the operating room for parathyroidectomy . The right superior parathyroid gland was found to be markedly enlarged and consistent with an adenoma . Her right superior parathyroid gland was removed and the rest of her parathyroid glands were left in place . Postoperatively , the patient did well and was able to cough and phonate completely with no changes from preoperative . The plan was to start her on heparin and Coumadin and discontinue her heparin when her Coumadin levels became therapeutic as judged by the prothrombin time / INR . However , on postoperative day number two , the patient in the afternoon noticed some tingling in her hands and also some tingling hear her perioral region . She had a negative Chvostek &apos;s and negative Trousseau &apos;s sign . She had no muscular weakness noted . An ionized calcium was drawn which was low at 1.0 . As a result , the patient was started on Os-Cal 250 mg PO q.i.d. On postoperative day number three , her ionized calcium was 1.06 and her Os-Cal was increased to 500 q.i.d. However , her ionized calcium decreased to 0.97 and she was given one amp of calcium gluconate . On postoperative day number five , the patient felt fine and had an INR of 1.9 with a prothrombin time of 16.6 . Her calcium was 8.5 , albumin 3.6 , and phosphate 4.5 . She had had no further episodes of tingling in her fingers after the initial episode which had prompted us originally to draw the ionized calcium . CONDITION ON DISCHARGE : Good . MEDICATIONS ON DISCHARGE : 1. Coumadin 5 mg PO q.day , then she will follow up with her primary care physician and decide the dosage thereafter , 2. Lopid 600 mg PO b.i.d. , 3. K-Dur 20 mg PO q.day , 4. Os-Cal 500 mg PO q.i.d. , 5. Rocaltrol 0.25 mg PO b.i.d. , 6. Lasix 40 mg PO q.day , 7. Norvasc 5 mg PO q.day , 8. Digoxin .25 mg PO q.day , 9. Lopressor 50 mg PO b.i.d. , 10. Glucotrol 10 mg qam . FOLLOW UP : For follow up , the patient is to call for an appointment with Dr. Sapmal . In addition , she is to follow up with her primary care physician to check her prothrombin time / INR as well as calcium , albumin and phosphate levels . She will be sent home with home Arnsperni Health . LENNI BREUTZOLN , M.D. DICTATING FOR : _____________________ RIEEA SAPMAL , M.D. TR : hzu DD : New Years Day TD : 01/06/97 2:48 P cc : RIEEA ODEE SAPMAL , M.D. CEALME LEOE MARESSYTHE Dr. Tokbelb Welle Health Sonsant .