EFTA00314225.pdf

Report Status: Final Quest EPSTF.IN, JEFFREY Drogrostics" Patient Information Specimen Information Client Information JEFFREY Specimen: MR047987t. Client N: 56W5265 F:PSTEIN, Requisition: 0006029 MOSKOWITZ, BRUCL W DOB: AGE: 65 IIRUCE MOSKOWITZ, MD Gender: M Attn: NATIONWIDE ACCOUNT Collected: 08/14/2018 Phone: 1411 N FLAGLER DR STE 7100 Received: 08/1412018 /21:21 EDT Patient ID: WEST PALM BEACIL FL 33401.3418 Reported: 08/192018 / 13:55 EDT I lealth ID: Test Name In Range Out Of Range Reference Range Lab PTH, INTACT AND CALCIUM PTH, INTACT 4/1 PARATHYROID HORMONE, INTACT 94 H 14-64 pg/mL Interpretive Guide Intact Calcium Normal Parathyroid Normal Normal Ilypoparathyroidism Low or Low Normal Low Hyperparathyroidlam Primary Normal or High High Secondary High Normal or Low Tertiary High High Non-Parathyroid Hypercalcemia Low or Low Normal High CALCIUM 9.8 8.6-10.3 mg/dL MI PERFORMING SITE: MI cast DlMlq KrMi Nlasll. 'tom nnttirRCE ‘np.o.oduLikei the taints^ Ileac. 01I N I IMAM:MD Pill) (11A Ilallon1134 CLIENT SERVICES: 866.697.8378 SPECIMEN: MR0479871. PAGE I OF I Qtiol. Quasi Dlatelostk; Iht owxhatil lag. sad sit ea...dried Quell Dbatausilrb mirk. art the trademark% orciaral EFTA00314225  Report Status: Partial 41 1)()uest —• °tannest ts EPSTEIN, JEFFREY Patient Information Specimen Information Client Information Specimen: MR0479851. Client a: 78300020 56W5265 EPSTEIN, JEFFREY Requisition: 0006030 MOSKOWITZ, BRUCE W 110B: AGE: 65 BRUCE MOSKOWITZ, MD t ;ender: M Atm: NATIONWIDE ACCOUNT Collected: 08/14/2018 MIMI:: 1411 N PLAGLER DR STE 7100 Received: 08115/2018 / 15:11 EDT Patient ID: WEST PALM BEACH. EL 33401-3418 Reported: 08/16/2018 107.59 EDT I lealth ID: Test Name In Range Out Of Range Reference Range Lab LIPID PANEL, STANDARD CHOLESTEROL, TOTAL 233 H c200 mg/aL MI HDL CHOLESTEROL 29 L >40 mg/dL MI TRIOLTCERIDES 541 H <150 mg/dt MI LDL-CHOLESTEROL mg/dL (talc) MI LDL cholesterol not calculated. TrigLyceride levels greater than 400 mg/dL invalidate calculated LW, results. Reference range: <100 Desirable range <100 mg/dL for primary prevention; <70 mg/dL for patients with CHD or diabetic patients with > or • 2 CHD risk factors. LDL-C is now calculated using the Martin-Hopkins calculation, which is a validated novel method providing better accuracy than the Friedewald equation in the estimation of LDL-C. Mar ' • • 2 1-20 a CHOL DL RATIO <5.0 Coale) MI NON HDL CHOLESTEROL 204 H <130 mg/ft Scale) MI For patients with diabetes plus I major ASCVD risk factor, treating to a non-HDL-C goal of <100 mg/dL (LDL-C of <70 mg/c1L) is considered a therapeutic option. HS CRP 1.3 mg/li TP Average relative cardiovascular risk according to MIA/CDC guidelines. For ages >17 Years: hs-CRP mg/L Risk According to ARit/CDC Guidelines <1.0 Lower relative cardiovascular risk. 1.0-3.0 Average relative cardiovascular risk. 3.1-10.0 Higher relative cardiovascular rink. Consider retesting in 1 to 2 weeks to exclude a benign transient elevation in the baseline CRP value secondary to infection or inflammation. >10.0 Persistent elevation, upon retesting. may be associated with infection and inflammation. HOMOCYSTEINE 20.5 <11.4 umol/L MT Homocysteine is increased by functional deficiency of folate or vitamin 612. Testing for methylmalonic acid differentiates between these deficiencies. Other causes of increased homocysreine include renal failure. tolare antagonists such as methotrexate and phenytoin. and exposure to nitrous oxide. CLIENT SERVICES: 866.697.8)78 SPECIMEN: 61110470831. PAGEIOF4 onto. (MA DlannodIri. the 0$14fiflitil lino and all assnriaied (Add Idatundllo mark. are the trademarks of Qunt Diagnirdlo. EFTA00314226  Report Status: Partial 40) Quest Diagnostics- EPSTEIN, JEFFREY Patient Information Specimen In fonnation Client Information Specimen: MR047985L Client ii: EPSTEIN, JEFFREY Collected: OW Is1/20I S MOSKOWITZ. BRUCE W DOB: AGE: 65 Received: 0S/15/20I8 / 15:11 EDT Gender: M Reported: 08/16,2018 / 07:59 EDT Patient II): Health ID: Test Name In Range Out Of Range Reference Range Lab COMPREHENSIVE METABOLIC MI PANEL GLUCOSE 95 65-99 mg/dL Pasting reference interval UREA NITROGEN (DUNI 22 7-25 mg/dL CREATININE 1.16 0.70-1.25 mg/dL For patients >49 yearn of age, the reference limit for Creatinine is approximately 13t higher for people identified as African-American. eGPR NON-APR. AMERICAN 66 OR • 60 mL/min/1.73m2 eGPR AFRICAN AMERICAN 76 > OR ra 60 mL/m1n/1.73m2 BUN/CREATININE RATIO NOT APPLICABLE 6-22 (talc) SODIUM 139 135-146 mmol/L POTASSIUM 4.4 3.5-5.3 mmol/L CHLORIDE 105 98-110 mmol/L CARBON DIOXIDE 23 20-32 mmol/L CALCIUM 9.0 8.6-10.1 mg/c1L PROTEIN, TOTAL 7.0 6.1-8.1 g/cIL ALBUMIN 4.2 3.6-5.1 g/dL GLOBULIN 2.8 1.9-1.7 g/dt (talc) ALBUMIN/GLOBULIN RATIO 1.5 1.0-2.5 (talc) BILIRUBIN, TOTAL 0.8 0.2-1.2 mg/di. ALKALINE PHOSPHATASE 55 40-115 U/L AST 23 10-35 U/L ALT 35 9-46 U/L HEMOGLOBIN Ale 5.7 H <5.7 i of total Hgb MI For someone without known diabetes, a hemoglobin Ale value between 5.7% and 6.44 is consistent with prediabetes and uhould be confirmed with a follow-up test. For someone with known diabetes, a value cit indicates that their diabetes is well controlled. A1c targets should be individualized based on duration of diabetes, age, comorbid conditions, and other considerations. This assay result is consistent with an increased risk of diabetes. Currently, no consensus exists regarding use of hemoglobin Aic (or diagnosis of diabetes for children. URIC ACID 8.3 H 4.0-8.0 mg/dL MI Therapeutic target (or gout patients: <6.n mg/dL TS" 2.31 0.40-4.50 14I T4 rfIlYROXINEI, TOTAL 7.9 4.9-10.5 mcg/dL MI FREE '14 INDEX (T71 2.4 1.4-3.8 T3 UPTAKE 30 22-35 MI SED RATE BY MODIFIED CLIENT SERVICES: X66.697.837); SPECIMEN: MR0.1791{5l. PaGE20F4 Quo.. Quo' Ilia¢umaa4 lilt *nodule( loo and atl IPPSOC int' 4.1(lots( Diagnenlii • m ark(1rr Ihr levileinarl• *Muni ' , jai:math.. EFTA00314227  Report Status: Partial 4iii Quest elagmntKi. EPSTEIN, JEFFREY Patient Information Specimen Information Client Information Specimen: MR047985L Client N: EPSTEIN, JEFFREY Collected: 08114/2018 MOSKOWITZ. BRUCE W DOB: AGE:65 Received: 08/15/2018 / 15:11 EDT Gender M Reported: dB/le/2018 / 07:59 EDT Patient ID: I learnt ID: Test Name In Range Out Of Range Reference Range Lab WESTERGREN 9 c OR 20 mm/h CBC (INCLUDES DIFP/PLT) MI WHITE BLOOD CELL COUNT 5.9 3.8-10.8 Thousand/uL RED BLOOD CELL COUNT 5.12 4.20-5.80 Million/uL HEMOGLOBIN 15.1 13.2-17.1 g/dL HEMATOCRIT 44.5 38.5-50.0 MCV 86.9 80.0-100.0 fL MCII 29.5 27.0-33.0 pg MCHC 33.9 32.0-36.0 g/dL RDW 13.8 11.0-15.0 PLATELET COUNT 248 140-400 Thousand/uL MPV 9.7 7.5-12.5 EL ABSOLUTE NEUTROPHILS 2879 1500-7800 cells/uL ABSOLUTE LYMPHOCYTES 2018 850-3900 cells/uL ABSOLUTE MONOCYTES 502 200-950 cells/uL ABSOLUTE EOSINOPHILS 443 15-500 colls/uL ABSOLUTE BASOPHILS 59 0-200 cells/uL NEUTROPHILS 48.8 LYMPHOCYTES 34.2 MONOCYTES 8.5 EOSINOPHILS 7.5 BASOPHILS 1.0 URINALYSIS, COMPLETE MI See Sndnote VITAMIN 612 371 200-1100 pg/m1 M1 Please Note: Although the reference range for vitamin B12 is 200-1100 pg/mL, it has been reported that between 5 and 10% of patients with values between 200 and 400 pg/mt may experience neuropsychiatric and hematologic abnormalities due to occult B12 deficiency; less than IS of patients with values above 400 pg/mL will have symptoms. C-REACTIVE PROTEIN 1.6 <8.0 mq/L MI EXTRA BLUE-TOP TUBE MI AN EXTRA SPECIMEN WAS RECEIVED WITH NO TEST REQUESTED. THE SPECIMEN WILL BE MAINTAINED IN STORAGE IN CASE ADDITIONAL TESTING IS NEEDED. PLEASE CALL THE CLIENT SERVICE DEPARTMENT FOR FURTHER ASSISTANCE. PROLACTIN 3.9 2.0-18.0 ng/mL MI TESTOSTERONE, TOTAL NI MALES (ADULT), IA TESTOSTERONE, TOTAL, MALES (ADULT), IA 150 L 250-827 ng/dL In hypogonadal males, Testosterone, Total, LC/MS/MS, is the recommended assay due to the diminished accuracy of immunoassay at levels below 250 ng/dL. This test code (15983) must be collected in a red-top tube with no gel. Endnifiel • Tent not performed. • No specimen received. • CLIENTSERVICESAW6497.8178 SPECIMEN:MR047985L PAGE30F4 ()ant Quasi Diagaddit f. hit alaudaled luau and all anacialtd Own ulapoults made are file Iradtmirla ofQmeiDimuents. EFTA00314228  Report Status: Partial raj we. Quest tkagnost;c5- EPSTEIN, JEFFREY Patient Information Specimen Information Client Information Specimen: KIR047985I. Client a: EPSTF:IN, JEFFREY Collected: 08/14/2018 MaSKOWITZ, BRUCE W DOB: AGE: 65 Received: OWI512018 !15:11 EDT Gender: At Reported: 08/1612018 I 07:59 EDT Patient ID: Health II): Endocrinology Test Name Result Reference Range Lab TT I rc• 30-100 ng/mL Vitamin 0 Status 25.0H Vitamin n: Deficiency: c20 ng/mL insufficiency: 20 • 29 ng/mL Optimal: or m 30 ng/mL For 25-OH Vitamin D testing on patients on D2-supplementation and patients for whom quantitatlon of D2 and D3 fractions is required. the OuestAssureD(TM) 25-OH VIT D. (O2.O3). LC/MS/MS is recommended. order code 92868 (patients >2yrs). For more Information on this test, go to' (This link is being provided for informationaU educational purposes only.) Physician Comments PENDING TESTS: MERCURY. BLOOD PERFORMING SITE: MI ttek‘T 111A0X0511COMAMI.102(0(0,1M11113 PARKWAV,M. it ttm$ utlt Ia.. mu, iltmai, 6111X I IIIAILCMDPIR4CtiA itallIMMI IP 014 'MI IIIMM0SlICS•1411119. 1!:3 1. 104 LI R 4VE ,1AMPA.1l I bil.:€1:4 ta.4 am.u. Ultlt ItORMS (1.14 Ifivit•OLYI CLIENT SERVICES: 866.697.8378 SPECIMEN: AIR0479851., PAGE 4 OF 4 punt. Qnnl Diagnostic% the aswdauA logo and all Snoclaird pore) MI/ignotlIts marls art the Iracleutarts of Qt.& btahauslits. EFTA00314229  Carnegie Hill Radiology 170 East 77th St New York, NY 10073-1912 Phone Pax Steven D. Wolff, M.D., Director CARDIAC AND CHEST CTA PATIENT: Epstein, Jeffrey DATE: July 29, 2018 AGE: 65 SIX: M ICA REFERRING: Dr. Bernard Kruger HISTORY Abdominal pain. COMPARISON To 2)8/2006. TECHNIQUE A low-dose gated cardiac and chest CTA were performed before and after the intravenous administration of 94 oft- of Isovue-370. The images were reviewed and reconstructed on a 3-D workstation. FINDINGS The coronary arteries originate normally from the aortic root and have a normal epicardial course. The left main is widely patent and free of plaque. In the proximal LAD there are focal calcified and soft plaque causing 30% to 49% stenosis. In the mid LAD there are focal calcifications causing 30% to 49% stenasis. The distal LAD is diffusely small in size with a small bulky calcification. The diagonal arteries are small in caliber. The circumflex Is widely patent. The obtuse marginal arteries are small in caliber. The RCA is dominant. The proximal and mid RCA is widely patent. The distal RCA and PDA are small in caliber. There is posterior right pleural thickening. No pleural or pericardial effusion is noted. There is no evidence for significant lymphadenopathy. There is diffuse thickening of the esophagus with fluid noted in the posterior medlastinum adjacent to the esophagus, which may be related to an inflammatory process. This was not seen previously. There is heterogeneity of the liver parenchyma, likely fatty liver. The ascending aorta measures 4.0 cm at the level of the sinuses of Valsalva. In the lateral left ea rib there is a bone island noted. In the right lateral 8th rib there is a bone island noted. There are degenerative changes of the osseous structures. IMPRESSION 1. The coronary calcium score is 84, placing the patient in the 25th to 50th percentile. It previously measured 41. 2. Nonobstructive atherosclerosis is noted in the LAD as described above. No definite obstructive corollary artery disease is noted. 3. There is nonspecific fluid noted in the posterior mediastinum adjacent to a diffusely thickened esophagus, which is indeterminate. This may represent an inflammatory or (continued) 0tteedxOanuer Bv1ai IZi230,11-11a With Mn , ) 2010470 Cardsc-OnniSTA Mnit(Clif0 an EFTA00314230  Carnegie Hill Radiology Cardiac and Chest aA Epstein, efircy July 29,2018 Page 2 of 2 infectious process. Advise correlation with endoscopy. A short-term blowup chest CT with contrast is recommended in 2 months to confirm resolution of these findings. 4. Hepatic steatosis. 5. There is thickening of the right posterior pleura, which may be due to infection and/or inflammation. M. Robed Peters, MD Ofith44CotepAre Sonia, (212)01.11a EFTA00314231 BIS Fax Server 1/30/2018 9:03:40 AM PAGE 2/004 Fax Server RichardJ.10MA M.D. 11mothyVV. Deyer, MD. Steven A. Albert, MD. James W. Brady, M.D. Stephen D. Greenberg, MD Gwen N. Harris, MD. Douglas R. [Thema; MD. Mam J. Winer, MD, Gavin L Duke, MD. Mark H. Plnab, Paul S. Ohol, MD. George Stases, MD. (rat) Sean K. Herman, M.D. Morton Schneider, MD. (net) Robed L. Ludwig, M.D. Alison Bender Halmos, M.D. (rot) 519 & 523 East 72nd Sheol • NewYork, NY 10021 • 9 East 76Ih Street AlFM"venue •New York, NY 10021 430 East 59th Street, Sutton Place • New York, NY10022 • 424 East Stith Mieet • New Yor K NY10128 Tel:212-286-1575 • Fax 212.288-7016 •www.eastrterknaging.00m BRUCE W MOSKOWITZ, M.D. 1411 NORTH RADLER DRIVE SUITE 7100 WEST PALM BEACH, FL 33401 Patient EPSTEIN, JEFFREY Exam Date: 1/30/18 Ace No: MRN: 0315192 Dear Dr. Moskowitz, CT NECK Clinical History: 65 y/o male with elevated PTH, concem for parathyroid adenoma. Technique: Multideteotor helical CT scans of the neckwere performed utilizing 40 parathyroid technique, from the superior orbital rim to the thoracic inlet using 2.5 mm slices, prior to and during the constant infusion of nonionic intravenous contrast. Multiphase postcontrast dynamic imaging was employed. Images were reconstructed at 1.25mm slice thicknesses at 1.25mm slice Intervals with corona! and sagittal reformats. Comparison: Neck MRI performed 11/30/2016 Findings:, The visualized brain parenchyma Is normal. The orbital contents are partially excluded from the field of view but are grossly normal in appearance. EPSTEIN, JEFFREY ACS Exam Date: vsorie not ACCESS YOUR PATIENTS IMAGES AND REPORTS WINW.EASTRIVERNAGINO.CONI PET/CT • HIGH FIELD MRI • OPEN MRI- MULTIDETECTOR VOLUME CT (VCTJ • DONEDENSITY • NUCLEAR MEDICINE ULTRASOUND • DIGITAL X•RAY • CORONARY CT ANGIOGRAPHY • VIRTUAL COLONOSCOPY• CT/MR ANSIOORAPHY EFTA00314232 RIS Fax Server 1/30/2018 9:03:40 AM PAGE 3/004 fax Server The masticator spaces are normal. The mastoid air cells and tympanic) cavities aro clear. Mid scattered paranasal sinus mucosal thickening is seen with areas appearing polypold In nature. Findings are worse along the left frontal drainage pathway which is occluded. A few of the maxillary and mandibular teeth have been endodonticalty treated. There is a left 2nd mandibular molar dental implant. Small bilateral mandibular tori are present The nasopharyry is normal. Prominence of the bilateral palatine tonsils are seen without deep extension, likely reactive in nature. Punctate calcifications Involve both palatine tonsils, &city reflecting remote inflammation. Minimal prominence of the bilateral lingual tonsils is seen without deep extension, likely reactive in nature. There is a tiny air-filled right Internal laryngocele, The hypopharynx and larynx are otherwise normal. The true cords are adducted. The major salivary glands including the parotid, submandibular and sublingual glands are normal. The thyroid is mildly heterogeneous. There is a 0.5 cm enhancing nodule within the posterior right midpole of the thyroid. There are no early enhancing parathyroid nodules. No discrete parathyroid mass is present. There Is no evidence for a parathyroid adenoma. There is no suspicious or pathologically enlarged cervical chain lymphadenopathy. There Is a partially imaged lipoma within the left supraclavicular fossa measuring 4.7 cm in greatest cranlocaudad dimension and 2.5 cm in greatest AP dimension. This is unchanged. There Is a bovine configuration of the great vessels arising from the aortic arch, a normal anatomic variant. There is patency of the major vessels of the neck. The pericervical musculature, scalene musculature and stemocleidomastoid muscles are normal asymmetric atrophy. The lung apices are clear. There is no suspicious mediastinal mass or evidence of ectopic parathyroid adenoma within the mediastinum on the images provided. Multilevel cervical spondylosis Is seen with disc herniations and superimposed disc osteophyte complexes resulting in multilevel ventral cord impingement as well as forarninal narrowing with suspected cervical nerve root Impingement id adenoma. EPSTEIN, JEFFREY ACC Exam Date: 1130/18 DOB: VA V: EASTRIVERMEDICAL WAGING, PC PET/CT-MOH FIELD MRI. OPEN MRI• MULTIDETECTOR VOLUME CT (VCT)• HONE DENSITY • NUCLEAR MEDICINE ULTRASOUND • DIGITAL X•RAY• CORONARY CT ANGIOORAIWY • VIRTUAL COLONOSCOPY • CT/MR ANGIOOFtAPHY EFTA00314233 RIS Fax 'server 1/30/2018 8:03:40 AM PAGE 4/004 Fax Sarver Mild s ercd polypoid paranasal sinus mucosal thickening with an occluded left frontal drainage A0.5 cm right midpo = thyroid nodule. Left el i lipoma, unchanged. Multilevel cervical epondylosis. Very truly yours, ADAM1MLNER, M.D. Electronically Signed By. ADAM 1NILNER, M.D. Date/Time Transcribed: 1/30/18 9:02am Contrast: Omnipague Contrast 350mg 100cc Creatinine 1.2mgkii REPORT CC: CC PATIENT EPSTEIN JEFFREY ACCT Exam Date: 1/30118 DOB: EAST RIVER MEDICAL IMAGING, PC www.aastriverlmagIng.com PRT/CT• HIGHFIELD MAI • OPEN MW • AlULTIDETECTOR VOLUME CT (VT) • BONEDENSITY• NUCLEAR MEDICINE ULTRASOUND • DIGITAL X-RAY• CORONARY CT ANOIOORAPRY• VIRTUAL COLONOSCOPY • CTIAIR ANGIOGRAPHY EFTA00314234  Nuclear Medicine Associates Nuclear SePET Imaging At Mount 1 Gustave Low Place #1141 Now York, Nit 10029 (212) 241.6969 Sinai (212)831-2M (fax) Rony Shlmony, MD Patient: EPSTEIN, JEFFREY 486 Madison Ave Sinai MR#: 17th Floor DOB: New York, NY 10022 Accession #: Date of Exam: 12/1312017 Examination: NM PARATHYROID SCAN 123 DOSING Dear Dr. Shimony: STUDY: Dual Isotope Parathyroid scan INDICATION: The patient presents with hypercalcemia, evaluate for parathyroid adenoma. METHOD: The patient received 0.2 mCi of I-123 orally. Anterior pinhole views of the neck were then obtained. Then the patient received 20 ma of Tc-99m Sestamibi Intravenously. Anterior pinhole views of the neck are obtained immediately followed by SPECT-CT Images of the neck and chest. Again, pinhole views of the neck at 2 hours are obtained. The low- dose nondiagnostlo CT scan images were obtained solely for the purpose of anatomic co-registration with the SPECT images. FINDINGS: There Is no prior study for comparison. The I-123 thyroid image shows homogeneous radlotracer distribution In both lobes of the thyroid gland. The early Sestamkil Image shows homogeneous radlotracer distribution In both lobes of the thyroid gland. The delayed Sestamibl image shows equal radlotracer washout from both lobes of the thyroid gland. SPECT-CT images show no abnormal focal uptake In the neck or chest. IMPRESSION: THERE IS NO ABNORMAL FOCAL UPTAKE IN THE NECK OR CHEST TO SUGGEST PARATHYROID ADENOMA. Thank you for the courtesy of this referral. Sincerely, Sherif I Melba, MD (Electronically Signed) Contrtbuling ProvIdor(c): 1) Melba, Sherif I 2) KESTENBAUM, DAVID EFTA00314235  Surgery Office Clinic Note Epstein, Jeffrey E - Final Report * * Final Report * Referring Physician Past Medical History Dr. Bruce Moskowitz Ongoing Primary hyperparathyroidism fridocrinolggist None Past Surgical History None Chief Complaint Primary Hyperparathyroidism Allergies No active allergies History of Present Illness Mr. Epstein, Jeffrey is a 65-year-old male who presents for surgical evaluation and Family History treatment, referred by Dr. Bruce Moskowitz. The patient presents with the diagnosis Mother: Deceased; Kidney disease of Primary Hyperparathyroidism and Hypercalcemia. The patient became aware of Father: Deceased; Heart disease the problem for about 10 years. He was previously evaluated by myself at Yale. At Brother (1): Alive and healthy that time, surgery was differed. Sister: None Children: None The patient does have a history ofnephrollthiasis (2 episodes 6 years No family history of endocrine disorders. ago). The patient does not take any thiazide diuretics or lithium. Social History His symptoms include constipation, trouble concentrating, and exacerbated fatigue. Smoking: None He experiences these symptoms sporadically and they correlate with elevated PTH Alcohol: None and calcium levels. The patient has no complaints of hoarseness, dysphagia, or Drugs: None difficulty breathing. The patient has no history of radiation treatment to head or Occupation: Banker neck. Laboratory and imaging are listed below. I have reviewed alllaboratory Home Medications results and images in details None Laboratory Studies, August 16th, 2018 (Quest Diagnostics) BUN: 21 [7-25] Creatinine: 1.16 [0.70-1.25] eGFR: 66 (>60] Calcium: 9.8 [8.6-10.3] it was 10.7 last week PTH, Intact: 94 (14-64] Vitamin D, 25-OH: 32 [30-100] TSH: 2.31 [0.40-4.50] Free T4: 2.4 [1.4-3.8] T 150 (250-800) according to the patient his LH and FSH are both normal as per patient had a 24 hour urine for calcium which was normal. Diagnostic Imaging and Procedures Parathyroid Scan, December 2017 (Mount Sinai, New York): IMPRESSION: There is no abnormal focal uptake In the neck or chest to suggest parathyroid adenoma. Result type: Surgery Office Clinic Note Result date: August 20, 2018 13:40 EDT Result status: Auth (Verified) Result title: Endocrine Surgery Consultation Performed by: Alonso, Rafael ARNP on August 20, 2018 13:42 EDT Verified by: Udelsman, Robert MD on August 20, 2018 14:49 EDT Encounter info: 903306115, MCI, Clinic, 08/20/2018 - Printed by: Cuevas, Yessenia OSHA Page 1 of 4 Printed on: 08/24/2018 11:21 EDT (Continued) EFTA00314236  Surgery Office Clinic Note Epstein, Jeffrey E - * Final Report " Neck CT (4D Parathyroid Technique), January 2018 (East River Medical Imaging, New York): IMPRESSION: No evidence for parathyroid adenoma. Mild scattered polypoid paranasal sinus mucosal thickening with an occluded left frontal drainage pathway. A 0.5 cm right mid pole thyroid nodule. Left supradavicular lipoma, unchanged. Multilevel cervical spondylolysis. Para Ultrasound Negative Bone density: as per patient was normal Review of Systems CONSTITUTIONAL: No fever, weight loss, or night sweats. EYES: No visual changes or eye pain. ENT: No sore throat, sinus pain, or ear pain. CARDIOVASCULAR: No chest pain or palpitations. RESPIRATORY: No cough, wheeze, or shortness of breath. GASTROINTESTINAL: No abdominal pain, nausea, or vomiting, + constipation ENDOCRINE: As above only. MUSCULOSKELETAL: No musculoskeletal pain or joint swelling. NEUROLOGICAL: No changes in special senses, no headaches. IMMUNOLOGY: No swollen lymph nodes HEMATOLOGY: No easy bruising or history of excessive bleeding. INTEGUMENTARY: No rashes or skin lesions. ALL OTHER: Negative Physical Exam Vitals & Measurements T: 37.2 °C (Oral) HR: 77 (Peripheral) RR: 16 BP: 123/74 SpO2: 96% WT: 88.5 kg (Measured) BMI: 27.01 Physical exam reveals a well•developed male GENERAL: No resting tremors EYES: Conjunctivae are not injected. No sclera' icterus. No exophthalmos. CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops. No carotid bruits. RESPIRATORY: Lungs are clear to percussion and auscultation. MUSCULOSKELETAL: No muscular atrophy. Gait normal. SKIN: Normal skin turgor, no obvious bruising. NEUROLOGIC: Oriented X3. Motor and sensory grossly Intact. THYROID: Examination of the neck reveals a normal thyroid gland. VOCAL CORDS: I was unable to visualize his cords by mirror exam. HEMATOLOGY/LYMPHATICS: There is no cervical or supraclavicular lymphadenopathy. Result type: Surgery Office Clinic Note Result date: August 20, 2018 13:40 EDT Result status: Auth (Verified) Result title: Endocrine Surgery Consultation Performed by: Alonso, Rafael ARNP on August 20, 2018 13:42 EDT Verified by: Udelsman, Robert MD on August 20, 2018 14:49 EDT Encounter info: 903306115, MCI, Clinic, 08/20/2018 - Printed by: Cuevas, Yessenia OSHA Page 2 of 4 Printed on: 08/24/2018 11:21 EDT (Continued) EFTA00314237  Surgery Office Clinic Note Epstein, Jeffrey E • Final Report Assessment/Plan 1. Primary hyperparathyroldism E21.0 --laboratory: 24 hour urine for calcium and creatinine -- Educational session and booklet provided to the patient This patient almost certainly has minor primary HPTH with a history of nephrolithiasis and neurocognitive symptoms. His imaging is negative making him at higher risk for multi-gland disease. I do believe he would be best served by parathyroid surgery and I explained this In detail. He will obtain his 24 hr urine collection in West Palm Beath and we will that after this study. -- I had a detailed conversation with the patient about his options. Based on the most current laboratory values, imaging studies, and physical examination, I have recommended: [Parathyroid exploration with the Intact PTH assay]. I explained the procedure as well as the risks, benefits, and potential complications to the patient. Risks include, but are not limited to, bleeding, infection, hypocalcemia, reaction to anesthesia, and injury to the nerves near the vocal cords. The patient verbalized understanding and has no further questions. We will proceed to surgery at a time convenient for the patient. I, Dr. Robert Udelsman had a face-to-face encounter with this patient, examined the patient and reviewed the APP notes. I have formulated the assessment and plan for this patient and reviewed them with the patient. A total of 40 minutes were spent face-to-face with the patient during this encounter and over half of the time was spent counseling and coordination of care. Discussed the operation, potential complications, post-operative recovery and management, past medical records including laboratory data and diagnostic imaging available at the time of the consult. Dr. Bruce Moskowitz is thanked for involving me in the care of this interesting patient. Robert Udelsman, MD, MBA, FAGS, FACE Endocrine Neoplasia Institute Miami Cancer Institute Baptist Health South Florida Signature Line Electronically Signed on 08/21/2018 07:33 Alonso, Rafael ARNP Result type: Surgery Office Clinic Note Result date: August 20, 2018 13:40 EDT Result status: Auth (Verified) Result title: Endocrine Surgery Consultation Performed by: Alonso, Rafael ARNP on August 20, 2018 13:42 EDT Verified by: Udelsman, Robert MD on August 20, 2018 14:49 EDT Encounter info: 903306115, MCI, Clinic, 08/20/2018 - Printed by: Cuevas, Yessenia OSHA Page 3 of 4 Printed on: 08/24/2018 11:21 EDT (Continued) EFTA00314238  Surgery Office Clinic Note Epstein, Jeffrey E - Final Report' Electronically Signed on 08/20/2018 14:49 Udelsman, Robert MD Completed Action List: * Perform by Alonso, Rafael ARNP on August 20, 2018 13:42 EDT * Modify by Alonso, Rafael ARNP on August 20, 2018 13:51 EDT * Modify by Alonso, Rafael ARNP on August 20, 2018 13:51 EDT * Modify by Alonso, Rafael ARNP on August 20, 2018 13:53 EDT * Modify by Alonso, Rafael ARNP on August 20, 2018 13:53 EDT * Modify by Alonso, Rafael ARNP on August 20, 2018 13:53 EDT * Modify by Alonso, Rafael ARNP on August 20, 2018 14:12 EDT * Modify by Alonso, Rafael ARNP on August 20, 2018 14:16 EDT * Modify by Alonso, Rafael ARNP on August 20, 2018 14:17 EDT * Modify by Alonso, Rafael ARNP on August 20, 2018 14:19 EDT * Modify by Alonso, Rafael ARNP on August 20, 2018 14:20 EDT * Modify by Udelsman, Robert MD on August 20, 2018 14:49 EDT * Sign by Udelsman, Robert MD on August 20, 2018 14:49 EDT Requested by Alonso, Rafael ARNP on August 20, 2018 14:40 EDT * VERIFY by Udelsman, Robert MD on August 20, 2018 14:49 EDT * Sign by Alonso, Rafael ARNP on August 21, 2018 07:33 EDT Requested by Alonso, Rafael ARNP on August 20, 2018 13:42 EDT Result type: Surgery Office Clinic Note Result date: August 20, 2018 13:40 EDT Result status: Auth (Verified) Result title: Endocrine Surgery Consultation Performed by: Alonso, Rafael ARNP on August 20, 2018 13:42 EDT Verified by: Udelsman, Robert MD on August 20, 2018 14:49 EDT Encounter info: 903306115, MCI, Clinic, 08/20/2018 - Printed by: Cuevas, Yessenia OSHA Page 4 of 4 Printed on: 08/24/2018 11:21 EDT (End of Report) EFTA00314239