The questions below deal with symptoms being experienced by a 16 year
old male. We fully acknowledge Google?s policy that ?Information
provided via the Services is not intended to substitute for informed
professional medical, psychiatric, psychological, tax, legal,
investment, accounting, or other professional advice.? And, as you
will see, we have already sought and are seeking professional medical
advice.
However, the advice to date has been in part unproductive and in part
contradictory. We would appreciate a review of the information below
to help identify clues that may have been overlooked or patterns that
the individual physicians, considering their own areas of
specialization, may not have noticed.
Are there tests that we should be asking doctors to conduct? Are there
conditions that, based on the information presented below, we should
ask the doctors to consider? In short, what information can you
provide from the information below that would assist us in identifying
and addressing the condition(s) affecting the patient?
Thank you.
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PROFILE
Patient DT is a 16 year old 10th grade student. Height: 5?2?, weight:
120 lbs. He is a fourth-degree martial arts black belt, and a varsity
wrestler. During wrestling season (November through February), Patient
DT works out approximately three hours per day. Patient DT is an A/B
student in school, which?for the most part?he enjoys.
PRE-EXISTING CONDITIONS:
· Obsessive-Compulsive Disorder
· Attention Deficit Hyperactivity Disorder
· multiple allergies
PRESCRIPTION MEDICATIONS:
· Zoloft (200mg daily) ? taken for last four years for OCD
· Allegra as needed (rarely)
SYMPTOMS:
Patient DT has been experiencing the following symptoms since mid-January 2006:
· constant dizziness (described as a lightheaded or ?spacey? feeling,
not a ?room spinning? sensation)
· weakness
· significant difficulty concentrating in class
· fatigue
· periodic nausea
· ?tightness? in upper left chest following exertion
Patient DT self-reported enlarged, non-tender lymph nodes in early
February. The nodes had reduced to normal size by the time of Patient
DT?s initial visit to the pediatrician on February 2 regarding this
cluster of symptoms.
Patient DT?s symptoms first became apparent to his parents at the end
of a long, difficult wrestling match on January 18 when Patient DT
reported that he felt very dizzy (he almost fell off the bleachers)
and nauseous (he almost vomited during the match).
Patient DT?s symptoms have gotten progressively worse. He has missed
many days of school, and has often gone home early due to feeling
unwell. Patient DT has reluctantly terminated his involvement in
wrestling. He is also unable to attend gym or weight training (a
scheduled school course), since these activities make him feel much
worse. Even passive activities (for example attending?not
participating in?a wrestling tournament) will wear him out.
RECENT HISTORY:
· Patient DT was diagnosed with impetigo on January 7, 2006. He was
treated with cephalexin 500 mg for five days and mupirocin 2%
ointment, and the impetigo appeared to resolve. However, during a
doctor?s appointment March 17, the physician identified a recurrence
of impetigo and placed Patient DT on another course of medication.
· Patient DT began to intentionally vomit on Thanksgiving day in an
effort to ?cut weight? for wrestling. This behavior did not come to
the attention of Patient DT?s parents until Christmas day, when he was
caught vomiting. Subsequent discussions revealed that Patient DT
binged and vomited on average three times a week, once or twice a day,
usually in the afternoon or evening, during the period between
Thanksgiving and February 2. He has not vomited since February 2.
· Patient DT has had a number of colds in the last several months.
· Patient DT?s urine is often concentrated (strong yellow) and
frequently cloudy. His stools sometimes are normal in appearance.
Sometimes, however, they are very pale and light in color.
DIET:
Prior to Illness
Patient DT enjoyed and ate substantial quantities of pasta and bread.
He generally would eat sugared cereals with milk for breakfast. At
school at lunch, his diet would vary, though seldom would it be
nutritious?ice cream or cookies, for example. In the afternoon,
returning from school, he would have a ?snack? of a Lean Cuisine or
Healthy Choice dinner selection. He generally would have a nutritious
dinner, and a bedtime ?snack? of several ounces of ice cream. During
the afternoon, he might also snack on sugared cereal. He would drink
several diet sodas a day, and perhaps one or two sports drinks
(Gatorade). During wrestling matches, he would have several ?power
bars? and bottles of Gatorade.
Currently
Based on various sources of advice (doctors, his wrestling coach, our
concerns), we have significantly reduced his sugar intake and
increased his protein consumption. Breakfast now often consists of a
large peanut butter (natural, no sugar added) and jelly (sugar-free)
sandwich. He is continuing to eat Lean Cuisines or Health Choices. He
has also begun eating salads?lettuce and other greens with strips of
chicken with moderate amounts of salad dressing. We have also
attempted to increase his intake of liquids, primarily water, though
only with moderate success.
BEHAVIORS
Patient DT does not drink alcohol or use tobacco (either smoke or
chew). He does not use drugs (other than prescription Zoloft, noted
above). We believe that he has not vomited since February 2.
BLOOD TESTS:
Patient DT has had CBCs and Comp. Metabolic Panels on February 2 and
March 13. Results from those two dates, respectively:
CBC
WBC: 6.0, .69
RBC: 4.19, 4.35
Hemoglobin: 13.1, 13.8
Hemocrit: 38.1, 40.0
MCV: 91, 92
MCH: 31.4, 31.7
RDW: 12.4, 12.7
Platelets: 260, 288
Neutrophils: 41, 50
Lymphs: 37, 29
Monocytes: 11, 9
Eos: 10, 12
Basos: 1, 0
Neutrophils (Absolute): 2.5, 3.5
Lymphs (Absolute): 2.2, 2.0
Monocytes (Absolute): 0.6, 0.6
Eos (Absolute): 0.6, 0.8
Baso (Absolute): 0.0, 0.0
Comp. Metabolic Panel
Glucose, Serum: 90, 94
BUN: 18, 15
Creatine, Serum: 0.9, 0.9
Sodium, Serum: 141, 142
Potassium, Serum: 4.2, 4.4
Chloride, Serum: 102, 103
Carbon Dioxide, Total: 29, 29
Calcium, Serum: 9.8, 10.4
Protein, Total, Serum: 6.8, 7.3
Albumin, Serum: 4.5, 4.6
Globulin, Total: 2.3, 2.7
A/G Ratio: 2.0, 1.7
Bilirubin, Total: 0.3, 0.2
Alkaline Phosphatase, Serum: 122, 88
AST (SGOT): 32, 24
ALT (SGPT): 24, 15
EBV
Patient DT was tested for EBV Acute Infection Antibodies on February
2, February 23, and March 7. The first test, on February 2, showed
positive/elevated titers on three of four tests. However, the two
subsequent tests show no elevation, and the director of the laboratory
that performed the tests says the February 2 positive results ?must be
a mistake.? Results from the three tests (February 2, February 23, and
March 7), respectively, are:
EBV Ab VCA, IgM: <20, <20, <20
EBV Early Antigen Ab, IgG: Positive, Negative, Negative
EBV Ab VCA, IgG: >170, <20, <20
EBV Nuclear Antigen Ab, IgG: 142, <20, <20
Lyme Disease
Patient DT was tested for Lyme Disease on March 2. Results were negative:
IgG/IgM Ab <0.91
Ab, Quant, IgM <0.91
Other Tests
Patient DT was tested for the following on February 23:
Phosphorus, Serum: 3.8
TSH: 2.517
Thyroxine (T4): 5.8
Amylase, Serum: 71
Magnesium, Serum: 2.1
Zinc, Plasma or Serum: 95
Pending Tests
Patient DT was tested on March 17 for cytomegalovirus and cat scratch
fever. (Family has two cats.) He is also being retested for Lyme
Disease, and having the CBC again. These tests were prescribed by an
infectious disease specialist (rather than his pediatrician), and may
use a different laboratory than the one used by his pediatrician (and
which produced the contradictory EBV readings). Results are not yet
available for these tests.
SPECIALISTS:
· Psychiatry:
Patient DT was seen by Psychiatrist AR at Hospital C outpatient on
February 21. He has been seeing Psychiatrist AR approximately every
three months for almost five years for OCD. Patient DT?s OCD has been
under control for at least four years. We addressed Patient DT?s
binging/purging behavior with Psychiatrist AR. She felt that
psychotherapy was not warranted at this time, since his
binging/purging seemed to be prompted by the desire to lose weight for
wrestling, and since he has stopped this behavior. Patient DT has a
follow-up visit with Psychiatrist AR April 4.
· Neurology:
Patient DT was seen by Neurologist C at Hospital C outpatient on
February 22. He was examined by her assistant. Neurologist C took
three blood pressure readings?prone, sitting, and standing?and
concluded that he had orthostatic hypotension. Patient DT?s blood
pressure did not decline upon sitting and standing (it went up);
however, his heart rate increased by 19 points. Neurologist C advised
substantially increased fluid intake and the addition of salt. Patient
DT is currently drinking additional fluids and we are giving him three
salt tablets (3 grams) per day. (From memory, so these numbers may be
off somewhat, his blood pressure was approximately 110/55. A month
later, with the salt tablets and water, it is approximately 120/75.)
Neurologist C stated that if Patient DT did not improve we might
consider a tilt-table test with Cardiologist JM. Neurologist C
suggested that we see a cardiologist to rule out heart involvement.
· Cardiology:
Patient DT was seen by Cardiologist MM on February 27. Cardiologist MM
conducted an EKG, which he stated was normal. Cardiologist MM then
conducted an echocardiogram. Based on this test, Cardiologist MM
stated that Patient DT has mitral valve regurgitation; however, this
was an ?incidental finding? which should not cause the symptoms that
Patient DT is experiencing. Cardiologist MM asked us to schedule a
stress test for Patient DT. Cardiologist MM advised Patient DT not to
engage in heavy weight-lifting, since it might make the mitral valve
regurgitation worse. Cardiologist MM conjectured that Patient DT has
?vasovagal overtone hypotension,? which he stated was synonymous with
Chronic Fatigue Syndrome.
Patient DT had a stress test with Cardiologist SH on March 10. During
the test, and without interviewing Patient DT, Cardiologist SH shared
his belief that Patient DT?s symptoms were psychogenic in origin, that
he needed to deal with his emotions, and that he should see a
psychiatrist. We later asked Cardiologist SH if he would have come to
the same conclusion if he were not aware of Patient DT?s psychiatric
history. He stated that he would, since he ?sees this all the time?.
He advised us to feed Patient DT nutritious meals and to have him
engage in aerobic exercise (which he used to do religiously).
Cardiologist SH also advised Patient DT not to engage in heavy
weight-lifting.
Patient DT?s mother attempted to make an appointment for a tilt table
test with Cardiologist JM at Hospital C, and was advised that Patient
DT must first be seen by a cardiologist at Hospital C. Patient DT was
seen by Dr. ? at Hospital C outpatient on March 16. She advised
Patient DT to drink more fluids and use more salt. She observed that
Patient DT?s regimen of increased fluids appears to be working since
his blood pressure and heart rate were within normal limits; however,
it might take him a while to feel batter. Dr. ? does not know why
Patient DT has constant dizziness, however. Dr. ? is making
arrangements for a tilt table test with Cardiologist JM.
· Infectious Disease:
Patient DT was seen by an infectious disease specialist on March 17.
As noted above, she had him tested for cytomegalovirus and cat scratch
fever, as well as retested for Lyme Disease, and having another CBC.
She also identified the reoccurrence of impetigo. And, upon seeing
Patient DT, she observed that he did not appear well?possibly a
reference to his appearing pale. As noted above, cardiology
specialists concluded that Patient DT?s weakness, dizziness, and other
symptoms are psychogenic.
· Pediatrician:
Patient DT had an annual physical on March 2. Pediatrician LB said
there is no medical reason for Patient DT?s symptoms. Pediatrician LB
suggested making follow-up appointments with Patient DT?s child
psychiatrist, a neurologist, and a gastroenterologist. She asked
Patient DT if he was having problems at school, having suicidal
thoughts, and other questions that implied that she does not believe
that he is ill or that he is taking drugs. Pediatrician LB was adamant
that Patient DT return to school as soon as possible.
FAMILY HISTORY (abbreviated):
· Maternal grandmother, age 88, has congestive heart failure.
· Maternal grandfather had numerous health problems (Parkinson?s
disease, several strokes, heart problems from rheumatic fever, etc. ?
died at age 52)
· Paternal grandmother, age 87, had a heart attack at approximately
age 80. Both paternal grandmother and sole aunt have had thyroid
disorders.
· Paternal grandfather died from a stroke at age 60 following years of
high blood pressure.
· Mother has had fainting problems in the past (abrupt faints during
early childhood, fainting when giving blood, near faint (extremely low
blood pressure) when given epidural, several other near faints).
Currently is obese and has hypertension. |
