Date of Service: Thursday, February 5, 2004
History: Ms. Clay is a 31-year-old woman who underwent endonasal transsphenoidal fenestration of an arachnoid cyst on February 4, 2003 at Harbor-UCLA. The patient's postoperative course was complicated by a CSF leak and meningitis which was treated with CSF diversion through a lumbar drain. Postoperatively, the patient felt much improved with improvement in her headaches and better overall sense of well-being. She continues to have relatively regular menstrual periods at this time. She does, however, complain of persistent total body aches and pains which she had prior to surgery. She has been able to return
to work and is selling computers.

Current Medications: Include Duragesic, Marinol, Neurontin, and Elavil, as well as Vicodin as needed for pain.

Physical Examination: Her visual acuity is 20/20 bilaterally using the near card without correction. Visual fields are full to confrontation. The extraocular movements are intact. There is no facial asymmetry. The patient has a normal gait. She has good nasal air flow bilaterally.

Imaging: The patient comes with an MRI obtained on January 30, 2004. This study shows the persistently enlarged sella which she had prior to surgery. There is no pressure on the optic chiasm and the pituitary stalk remains slightly pushed anteriorly. There is no evidence of pressure effect from the remains of the arachnoid cyst in the sellar and suprasellar area. No other abnormalities are noted.

Hormonal Testing: The prolactin level is mildly elevated at 34.2 ng/ml. IGF-1 is pending.

Impression: Ms. Clay remains neurologically stable and improved one year after undergoing fenestration of a sellar and suprasellar arachnoid cyst. Her magnetic resonance imaging suggests that the arachnoid cyst remains fenestrated and has not re-formed. She is having normal menses but has a mildly elevated prolactin level. She will be recommended to follow up with an endocrinologist and may need to be placed on a dopamine agonist and tested for growth hormone deficiency.

She was recommended to send her old MRIs for evaluation and comparison to the present MRI and was also told that she should continue to have annual MRIs. The patient will be seen in followup on an as-needed basis.

Daniel Kelly, M.D.
Electronically signed (2/8/2004 6:9:43)
MD5 checksum: afa4c592b2b0c461ce5d233796edee5c
cc:
PEJMAN COHAN
Dictated: 2/5/2004 18:27
By: Daniel Kelly, M.D.
Reference number: M1-402061085844300
Transcribed: 2/6/2004 17:27
By: /EDIX
Reference number: 02065844.300
Received: 2/6/2004 17:21
Document ID Number: 2241913
Patient UI Number: 103106647
Filing number: 003

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