K.M. is a 16 year old high school honor student with a history of Tetrology of Fallot who underwent a parathyroid- ectomy 1 month ago. He is now referred because of insomnia. HPI: The patient was in his usual state of good health when he went for a "routine" physical examination. He was found to have a serum calcium of 12.0 mg/dl. A repeat calcium was 12.1 with a serum PTH of 9 pmol/L (nl < 5.2). A sestimibi scan demonstrated left parathyroid uptake. The patient underwent a parathyroidectomy and surgical pathology confirmed resection of a parathyroid adenoma. He was discharged from the hospital without complications. Several days after surgery the patient complained of insomnia. The problem persisted and resulted in a decrease in academic performance. A pediatrician thought the patient was depressed from his surgery.
Past medical history was remarkable for repair of Tetrology Family and Social History were unremarkable. There was no family history of parathyroid or thyroid disease.
Medications:
Calcium carbonate (he was not compliant
with this)
Celexa 20 mg qAM
Benadryl PRN qHS (not helpful)
Physical
Examination:
Bp
108/58; P 120/min, regular. Weight was 56.2 Kg, height 173 cm. He was a
well developed, well nourished, shy, white male, looking his stated age. Eyes were normal.
There was a well healed surgical scar over the thyroid bed. The thyroid size was 10g, and without
masses. There was no adenopathy. Lungs
were clear. The cardiac exam revealed a III/VI systolic murmur that was heard
throughout the precordium. A fine
tremor was noted. The skin was normal.
Which of these tests/consults would you order at this point?
Serum
calcium
Serum
TSH
Serum
T4/FT4I
Chemistry
Panel
CBC
Psychiatry
Consult