Patient states that he went to sleep on Thursday night 10/31 and when he woke up Friday morning he had a headache and some eye irritation in the right eye, along with decreased vision. This was about 1 week ago. It's doing about the same or a little bit worse. He started the eye drops about 2 days ago and one yesterday. He is on homatropine, timolol and durazol. Patient is now getting gamma-globulin. For the entire month of September he had 103 degree fever. He had a second opinion from a doctor at Moffit. There was suspicious that the T-Cell count was low. He was on prednisone and has now tapered to 5 mg per day. He is to taper off by Sunday. He started on high dose prednisone 60 mg per day in September. He has not had a port in for a few years. He had no indwelling catheters in the hospital. VA OD: sc20/125-2 PH20/40-2 NccJ10 OS: sc20/16 PHNI NccJ1+ IOP: TP OD: 21 OS: 14 Posterior Segment: Findings OD: Nerve: Pink. Sharp. CDR-V 0.5. Vitreous: Vitreous Syneresis. Mild Diffuse Cells. Retinal Vessels: Attenuated Vessels. Macula: No Hemorrhage. No Subretinal Fluid. No Edema. Because of the possible diagnoses, PCR was sent of the anterior chamber which came back positive for toxoplasmosis and negative for herpes viruses. The patient was treated with Bactrim DS for 6 weeks and no steroids and completely resolved. The lesion grew a little bit. |
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Patient states that he went to sleep on Thursday night 10/31 and when he woke up Friday morning he had a headache and some eye irritation in the right eye, along with decreased vision. This was about 1 week ago. It's doing about the same or a little bit worse. He started the eye drops about 2 days ago and one yesterday. He is on homatropine, timolol and durazol. Patient is now getting gamma-globulin. For the entire month of September he had 103 degree fever. He had a second opinion from a doctor at Moffit. There was suspicious that the T-Cell count was low. He was on prednisone and has now tapered to 5 mg per day. He is to taper off by Sunday. He started on high dose prednisone 60 mg per day in September. He has not had a port in for a few years. He had no indwelling catheters in the hospital. VA OD: sc20/125-2 PH20/40-2 NccJ10 OS: sc20/16 PHNI NccJ1+ IOP: TP OD: 21 OS: 14 Posterior Segment: Findings OD: Nerve: Pink. Sharp. CDR-V 0.5. Vitreous: Vitreous Syneresis. Mild Diffuse Cells. Retinal Vessels: Attenuated Vessels. Macula: No Hemorrhage. No Subretinal Fluid. No Edema. Because of the possible diagnoses, PCR was sent of the anterior chamber which came back positive for toxoplasmosis and negative for herpes viruses. The patient was treated with Bactrim DS for 6 weeks and no steroids and completely resolved. The lesion grew a little bit.
