Ophthalmology System

DISCHARGE SUMMARY

FINAL DISCHARGE DIAGNOSES

1. Cytomegalovirus retinitis, left eye.

2. Molluscum contagiosum.

SUMMARY OF HOSPITALIZATION

This 36-year-old white male with positive HIV antibody, acquired immune deficiency syndrome, and prior Pneumocystis carinii pneumonia was admitted to the hospital with progressive deterioration of vision in his left eye due to cytomegalovirus retinitis.  After informed consent was obtained, the patient was started on antiviral therapy with ganciclovir.  At the time of initiation of therapy, the patient’s CBC showed a hemoglobin of 11, hematocrit of 32.8, a white blood cell count of 1600 with
41 segs, 1 band, and platelets 158,000.  Serum creatinine was 1.0, and BUN was 8.  Liver function tests were normal.

Patient was given ganciclovir 5 mg/kg twice a day.  After 2 days of therapy, the patient’s WBC had dropped to 1600 with 28% segs, and the ganciclovir was held for 36 hours.  Following this his white blood cell count recovered well enough so that the ganciclovir was restarted at the same dose.  He received subsequent 3 days of ganciclovir therapy in the hospital.

Prior to discharge his final WBC was 1900 with 63% segs and
2 bands.  Hemoglobin was 11.9, hematocrit 35.6, platelets 158,000.  Additional laboratory values showed negative serum RPR and negative Toxoplasma antibody.

The patient was discharged to complete IV ganciclovir therapy for 2 weeks at home.  Discharge medications include ganciclovir
300 mg IV q.12h. for 14 days, pentamidine aerosol 150 mg twice a month, and Nizoral 200 mg p.o. p.r.n.  I will see the patient back in the office in followup in 2 weeks.

Also, while the patient was in the hospital, he was seen in dermatology consultation and had cryotherapy to remove several lesions of molluscum contagiosum from his face.

FOOTNOTE

Lines 35, 37.  Alternative:  I.V.