Consulting Physician: Dr. Taujan Georgiana Cristina
Chief Complaint and History
Reason for Consultation
Follow-up appointment for management of a large pituitary macroadenoma with associated central adrenal insufficiency and thyroid dysfunction. The patient reports significant improvement in fatigue, memory problems, and decreased libido.
Medical History
2022: Vision problems in right eye diagnosed during ophthalmology consultation in Zambia
Since 2022: Balance difficulties, particularly when cycling
Current diagnosis: Large pituitary macroadenoma with compression effects
Non-smoker, no alcohol abuse, lives independently at home
Physical Examination
Vital Signs
Parameter
Value
Status
Height
170 cm (5'7")
Normal
Weight
112.5 kg (248 lbs)
Obese
BMI
38.9
Obese
Blood Pressure
195/85 mmHg
Hypertensive
Heart Rate
76 beats per minute
Normal
Clinical Findings
No current headaches
Erectile dysfunction resolved
Central obesity with abdominal fat distribution
Diagnostic Studies
Brain MRI (November 7, 2024)
Findings:
Large pituitary macroadenoma measuring 25 × 35 × 37 mm
Bilobed appearance with suprasellar extension
Compression of optic chiasm
Extension into cavernous sinuses with engorgement of internal carotid arteries
Clinical Significance: This is a substantial tumor requiring surgical intervention.
Ophthalmology Consultation (November 2024)
Visual Field Testing:
Right eye: Superior temporal visual field loss (stable)
Left eye: Complete temporal visual field loss, both superior and inferior (stable)
Assessment: Pituitary adenoma causing chiasmatic compression, more severe on the left than right. Optical coherence tomography shows mild changes. Surgery scheduled for early 2025.
Neurosurgical Consultation
Patient evaluated by Professor Raftopolous on December 3, 2024. Surgery planned for February 2025.
Laboratory Results
Recent Blood Work (January 13, 2025)
Complete Blood Count: All values within normal range
Hemoglobin: 13.9 g/dL (normal)
Red blood cells: 4.80 million/μL (normal)
White blood cells: 5.46 thousand/μL (normal)
Platelets: 173 thousand/μL (normal)
Metabolic Panel:
Fasting glucose: 116 mg/dL (pre-diabetic range)
Sodium: 142 mmol/L (normal)
Potassium: 3.8 mmol/L (normal)
Creatinine: 1.10 mg/dL (normal kidney function)
Hormone Levels:
Thyroid function:
TSH: 1.91 mUI/L (normal, but trending up from previous)
Free T4: 8.0 pmol/L (low-normal)
Adrenal function:
ACTH: 25.9 ng/L
Cortisol: 161 nmol/L (on replacement therapy)
Reproductive hormones:
Testosterone: 14.18 nmol/L (improved from previous)
LH: 4.1 UI/L
FSH: 30.6 UI/L
Growth hormone axis:
IGF-1: 65 μg/L (low)
Growth hormone: <0.05 μg/L (low)
Prolactin: 21.6 μg/L (controlled with cabergoline)
Lipid Profile: Generally acceptable levels
Total cholesterol: 193 mg/dL
HDL cholesterol: 57 mg/dL
LDL cholesterol: 121 mg/dL
Triglycerides: 72 mg/dL
Assessment and Plan
Current Status
The patient's pituitary macroadenoma remains large and is causing:
Visual field defects due to optic chiasm compression
Metabolic complications including obesity and pre-diabetes
Treatment Plan
Immediate Actions:
Urgent surgical consultation - Patient scheduled for transsphenoidal surgery in February 2025
Start thyroid hormone replacement - L-thyroxine 25 mcg daily for 7 days, then increase to 50 mcg daily, taken on empty stomach
Continue current medications - Maintain hydrocortisone, cabergoline, and other medications
Lifestyle Modifications:
Diet: Low-calorie, low-carbohydrate diet for weight management
Exercise: Increase physical activity intensity for weight loss
Monitoring: Pre-diabetes management
Follow-up:
Return visit in 2 months for post-surgical evaluation and hormone level monitoring
Coordinate care with neurosurgery team for perioperative management
Prognosis
With appropriate surgical treatment, most patients experience improvement in visual symptoms and hormone function. The patient's current symptom improvement on medical therapy is encouraging for post-surgical outcomes.