A 49-year-old caucasian lady was referred to us by her primary care physician for evaluation of hypercalcemia. Two weeks prior to presentation she was found to have high calcium level of 12.5 mg/dL after routine blood work was performed. Hypercalcemia was reconfirmed by repeating bloodwork. She reported a history of fatigue, irritability, poor sleep, poor memory along with depression and anxiety. She did not have a history of nephrolithiasis. Her past medical history was significant of psoriatic arthritis, hypertension and depression. Her medications included Sulfasalazine, methotrexate, etodolac, meloxicam, propranolol, duloxetine and citalopram. Calcium level was 12.5 mg/dL and intact PTH level was 217 pg/mL. A diagnosis of primary hyperparathyroidism was confirmed. A real time ultrasound in the clinic showed an enlarged right inferior parathyroid gland and a NM parathyroid Spect CT showed an enlarged right inferior parathyroid gland. As two imaging studies were concordant, she met the criteria for a minimally invasive/focused parathyroid surgery. Transoral endoscopic parathyroid surgery vestibular approach was offered as she was motivated to avoid a scar in the neck. Following excision of the right inferior parathyroid gland, the intraoperative PTH(IOPTH) level dropped by more than 50% and to the normal range.