Age: 9.0
Sex: M
Vaccine: FLUN(H1N1), FLUN(H1N1), FLUN(H1N1), FLUN(H1N1), FLUN(H1N1)
Symptoms: Blood urea nitrogen/creatinine ratio increased, Blood urea normal, Carbon dioxide normal, Central nervous system lesion, Culture throat negative
Clinical narrative: This is additional information taken from my daily journal to supplement what was previously reported, including sudden reappearance of inability to walk again, but this time due to severe joint and muscle pain.  Information here is provided in the hopes of helping to identify patterns since I have detected MANY critical errors of omission and commission in the documentation provided by nurses and physicians in the medical records that I obtained.  Chronological Account from 12/8/09-3/3/10:  Tuesday, 11/17/2009:  Had intractable coughing spells.  Diagnosed with acute bronchitis.  Started on azithromycin and prednisolone X 5 days and Tussionex  and prn albuterol.  Saturday, 11/21/2009:  Finished last doses of azithromycin, prednisolone, and stopped Tussionex because coughing intractable coughing spells stopped.  Had rare (occasional) cough, so continued prn albuterol.  Thursday, 11/27/2009:  Last dose of prn albuterol.  He had stopped taking it because he felt fine and had no more coughing spells and cough was very rare and mild.   12/8/2009:  Approximately 12:30 p.m., 12 days after pt had taken his last dose of prn albuterol and 17 days after his bronchitis had resolved with antibiotic treatment, he received H1N1 nasal spray even though I had reported to school nurse that he had had acute bronchitis and was taking prn albuterol.  Vaccine was administered at school.  By about 2:45 p.m., pt appeared very tired.  Did not eat dinner and went to bed at 5:00 PM. Woke up at 6:00 PM and I (pt.'s mother) made him eat dinner.  After eating dinner, he suddenly complained of dizziness, not feeling good, and of shaking. I noticed that pt exhibited what appeared to be myoclonic jerks. I noticed this as he was sitting and walking. Temperature was 97.5 axillary. Pulse 75. No sweating. Forehead felt slightly warm to the touch. He was awake and oriented to person, place, and time, but stated he did not feel good. He looked tired. I called the pediatrician's office and was told to take him to the emergency room. Taken to the emergency room at 7:00 PM. While patient was sitting in the emergency room waiting to be seen by the physician, I noticed what appeared to be myoclonic jerks again, accompanied by patient's complaint that he felt very sleep. He started to close his eyes and I physically stimulated him to keep him awake by talking to him and massaging his head and shoulders. Patient was examined by emergency physician at approximately 7:30 PM. Pulse was 65 according to emergency room automatic blood pressure machine. By 8:15 PM, pt stated that his dizziness was decreased and that he felt better, but he said that he still did not feel ""right"" like his usual self. I noticed that he no longer exhibited any jerky movements by this time. I took his pulse by palpation and it was 60. Emergency physician noted that while patient was ""distracted"" by activity, such as standing and sitting, there were no jerks. Patient was sent home without treatment and was told to follow up with primary care provider in the morning.  12/8/2009, 12/9/2009, 12/10/2009:  Extreme sweating to the point of drenching bed sheets.   12/10/2009:  Fever 99.7  12/14/2009:  Dizzy.  Irregular heart rate.  Wheezy.  RSV and flu tests negative.  Started medications prednisolone and azithromycin.  Pediatrician also ordered Tussionex but insurance did not cover this medication, so my son did not take this medication.  Resumed albuterol q 4 hours due to physician's order.    12/18/2009:  Severe dizziness, apical pulse 52 standing and 42 supine, headache, weak and sleepy.  My son had reported parietal headaches only and at one time recently since getting the vaccine, he had reported left temple headache, but I can't recall the exact date.  Had finished last doses of azithromycin and prednisolone this morning.   12/21/2009:  Early a.m. stool incontinence in a child who has never had stool incontinence since being toilet trained. 12/27/2009:  12:27 p.m.:  Baseline VS before jogging:  P 80, R 22 unlabored, slight dizzy.  12:41 p.m.:  VS 5 minutes into jogging:  P 111, R 22 and labored.  12:46 p.m.:  VS 5 minutes after resting from jog:  P 90, R 19 labored, very dizzy.  Diminished air exchange in lungs to auscultation.  12:59 p.m. (VS 13 minutes after resting):  Pulse up again to 106, Respirations 12.  Dizzy.  Took 2 puffs albuterol and breathing less labored.  7:30 p.m.:  First appearance of unsteady gait:  Very dizzy and holds onto walls to keep his balance.  (Compare this to the psychiatrist's later report that patient has no balance problems when he is standing up against the wall.)  7:52 p.m.  Myoclonic jerks after eating.  Dizziness continues all day.  8:02 p.m.:  Myoclonic jerking stopped.  Feels a little dizzy. 12/28/2009:  6:00 am. : Very dizzy, HR low 51.  9:00 a.m. : Unsteady gait (ataxia).  Accompanied by dizziness, sleepiness.  Has myoclonic jerks after he takes drink of water.  7:46 p.m.:  By this time, he has been having myoclonic jerking on and off for about 11 hours.  8:52 p.m.:  Insomnia, first report of feeling like he is boiling hot inside.  Dizziness continues. 1/2/2010:  Sudden onset of chills and fever of 102.4 axillary. Unable to sweat despite fever. 1/3/2010:  Fever 102.2 axillary, irregular HR 89, unable to sweat, we made him drink a lot of water and I checked and his urine is clear yellow.  New onset of sore throat.  1/4/2010:  6:00 a.m.:  Started to feel hot inside again.  Still has sore throat and cough and has trouble swallowing due to pain/swelling of throat.  1:30 p.m.:  Afebrile.  No complaints of dizziness.  Singulair prescribed for asthma for the first time ever.  No hx of asthma, only had acute bronchitis back in 11/17/2009 that had precipated severe intractable coughing spells.  Bronchitis and coughing spells resolved with azithromycin, Tussionex, and prn albuterol.  Last dose of albuterol had been on 11/26/2009, 12 days before administration of H1N1 nasal vaccine on 12/8/2009.   Nasal tests  negative for RSV and H1N1.  Rapid strep test negative.  9:45 p.m.:  Stuffy nose, decongestant not helping; took first dose of Singulair.  Resumed albuterol inhaler q 4 hr, not prn, per pediatrian's request.  These drugs dramatically improved cough.  1/5/2010:  12:52 a.m.:  Still moderately stuffy nose, saline nasal drops worsened nasal congestion.   4:30 p.m.:  hot, dizzy, feels "twitch," water eyes, personality change:  does not talk when talked to and seems despondent and depressed?  Only scribbles answers to questions on a piece of paper. Axillary temp 95.2.  HR 60.  5:06 p.m.:  Sleepy, tired, wheezy despite having taking 2 puffs albuterol at 2:38 p.m., bradycardia (pulse 51, irregular).  I made him drink a lot to try to raise his pulse.  6:38 p.m.:  Feeling hot inside, wheezy, took 2 puffs albuterol inhaler.  8:00 p.m.:  Applied Takara Detox Foot Patches to try to detox him.  No more coughing.  Mild nasal congestion present.  8:32 p.m.:  Nasal congestion improved.  Night time myoclonus present.  11:50 p.m.:  He resumed his normal moderately sweating that he has always had prior to getting the H1N1 vaccine.    1/6/2010:  5:45 a.m.:  Feeling very hot inside, not feeling good, very tired.  Needed assistance to ambulate.  6:00 a.m.:  Myoclonic jerks noted after eating breakfast.  6:15 a.m.:  No more myoclonic jerking.  Feels very hot inside.  1:00 p.m.:  Mild nasal congestion, sitting BP 96/64, pulse 54 sitting.  From sitting to standing, pulse remains slow and did not change.  Cardiologist's conclusion:  dysautonomia.  Cardiologist coded diagnosis as 780.4, which is dizziness and giddiness according to the 2010 ICD-9-CM.  8:00 p.m.:  Singulair administered to him.  Mild nasal congestion and mild dizziness present.  DENIES HEADACHE, DENIES FEELING HOT INSIDE.  9:45 p.m.:  dizzy on and off all day today.  Pulse in the 50s.  Feeling hot inside.  Sleeping with only underwear on.  This is the way he usually sleeps before getting the H1N1 vaccine.  Is coldness the trigger that causes him to feel hot inside?  I suspect so.  Therefore, I made him dress in clothes to go to bed and do not let him sleep with just his underwear on tonight.  He has insomnia.    10:30 p.m.:  Sweated a little; this is not the moderate sweating he has always had before he got the H1N1 vaccine.  Mild nasal congestion.  Insomina.  Personality change:  When I converse with him about how he feels, he would not talk to me.  He used only hand signals and nods.    1/7/2010:  1:05 a.m.:  Severe stuffy nose.  Irregular, shallow breathing, then apnea; I stimulated him to breathe again by shaking him.  He resumed shallow, irregular breathing.  5:45 a.m.:  FIRST DAY BACK AT SCHOOL.  Dizzy, tired, pulse 56.  2:00 p.m.:  HAD SUDDENLY BECOME TIRED AFTER LUNCH AND UNABLE TO AMBULATE UNASSISTED.  EXHAUSTED AND WANTED TO NAP NOW, SO I SENT HIM TO BED.  3:30 P.M:  EXHAUSTED BUT HAD NOT BEEN ABLE TO FALL ASLEEP DURING ATTEMPT AT NAPPING.  6:27 P.M.:  OCCASIONAL COUGH, CLEAR NASAL DRAINAGE, TOOK ALBUTEROL INHALER.  6:59 P.M.:  SUDDEN DIZZINESS AFTER EATING, PULSE 56, NO COUGH, STARTING TO FEEL HOT INSIDE.  COLD ARMS, SO I MADE HIM DRESS WARMLY.  6:59 P.M.:  NO WHEEZING.  I NOTICED THAT HIS COUGHING HAS ALMOST COMPLETELY STOPPED SINCE STARTING SINGULAIR.  HIS DIZZINESS HAD IMPROVED BEFORE STARTING SINGULAIR, BUT HAD RESUMED AFTER STARTING SINGULAIR.  THIS MAKES ME WONDER IF SINGULAIR IS WORSENING HIS DIZZINESS?  I GO AHEAD AND ADMINISTER 5 MG OF SINGULAIR TO HIM AS ORDERED.  8:30 P.M.:  FEELS A LITTLE HOT INSIDE.  I DRESSED HIM WARMLY IN RESPONSE, BECAUSE I NOTICED THERE SEEMS TO BE A PATTERN:  COLD DRINKS AND A COLD ENVIRONMENT TRIGGERS THE FEELING OF BEING HOT INSIDE.    10:30 P.M.:  DRESSING WARMLY SEEMS TO LESSEN OR PREVENT THE FEELING OF BEING HOT INSIDE:  HE SWEATED A LITTLE AND HAS NO COMPLAINT OF FEELING LIKE HE IS BURNING UP INSIDE.   1/8/2010:  5:48 A.M.:  Severe parietal headache, severe dizziness, blurry vision, unable to get out of bed, galloping heart rhythm  with rate of 47 to auscultation.  I gave him one cup of water to drink because that was all he could drink.  6:35 A.M.:  Apical pulse 52.  7:04 A.M.:  ATAXIA.  Headache gone, dizziness still present but improved.  10:45 A.M.:  WALKED FROM PARKING LOT WITH ATAXIC GAIT AND WITH ASSISTANCE TO PEDIATRICIAN'S OFFICE.  WHILE WAITING IN EXAM ROOM TO BE EXAMINED, PT. BECAME EXTREMELY SLEEPY, APPEARED TO FALL ASLEEP, SUDDENLY A SMILE APPEARS ON HIS FACE INAPPROPRIATELY AND HE DOES NOT RESPOND TO PHYSICAL OR VERBAL STIMULI FROM ME OR HIS FATHER.  THIS SMILING WAS ACCOMPANIED BY MYOCLONIC JERKING. (POSSIBLE GELASTIC SEIZURE?)  BP 92/68 SUPINE, RADIAL PULSE 48 SUPINE.  TAKEN TO EMERGENCY ROOM.  12-lead EKG with sinus bradycardia with sinus arrhythmia and (HR down to 48 beats per minute) and showing borderline prolonged QT interval.  3:27 P.M.:  Hospitalized. Attending MD notes pt's left eye does not converge BUT DOES NOT TELL PARENTS (I FOUND OUT FROM OBTAINING PT'S MEDICAL RECORD ON MY OWN). She documents in medical record that she spoke with pediatric cardiologist who said patient has dysautonomia and his arrhythmia reflects dysautonomia and is not indicative of primary cardiac problem.  She also documents that pediatric cardiologist said the drug Florinef (fludrocortisones) had been considered for treatment, but I had not wanted to put my son on another medication.  (This was true on 1/6/2010, when I told the pediatric cardiologist that I expected his bradycardia to resolve on its own, and if not, I would consider the use of Florinef.)  Attending MD documented that she agreed with pediatric cardiologist's assessment.  However, no treatment was instituted.   9:41 p.m.:  Feels hot inside and outside; this is unusual.  Has complained of feeling burning/boiling inside but never has complained of feeling hot both outside and inside before. No wheezing.  MDs had not ordered pt to continue taking his asthma medications (Singulair 5 mg at h.s. and prn albuterol inhaler) while in the hospital; no reason given.  1/09/2010:  Early a.m.:  My son's IV fluid had been infusing at 10 mL/hr.  RN stated that since he would be NPO for MRI, she would ask the doctor if the IV fluid should be increased.  RN came back and increased IV rate to 80 mL/hr.  I noticed that within minutes of this rate increase, patient's heart rate on the cardiorespiratory monitor dipped repeatedly into the 40s.  I told the RN and she came and observed the heart rate dipping into the 40s as well.  Then after several minutes of this irregularity, the heart rate came up to 51 and 52.   1/09/2010:  6:05 A.M.:  Apnea accompanying HR in the 40s.  I was sleeping at pt's bedside in the hospital and heard and saw respiratory line go flatline.  I immediately jumped and checked cables and all were intact.  I vigorously shook him and he awoke.  Then I let him resume sleeping and immediately left the room and retrieved the RN.  RN came into room and we both observed cardiorespiratory monitor showing multiple HR dips into the 40s and pt's Respiratory Rate becoming shallow.  RN failed to document the apnea and flatline I had reported to her.  She only charted HR dipping into 40s and shallow breathing 15 breaths/minute.  (I found this out after I had obtained full medical record myself and reviewed the chart.)   10:30 a.m.:  Pediatric neurologist, barely in the room two minutes with pt. and diagnoses him with true conversion disorder and says nothing will be found on the MRI and LP.  Later in the day, MRI reveals intrasellar lesion that has displaced pt's pituitary gland away from midline and caused it to bulge upward. The MRI report says "The appearance is suggestive of an adenoma that has perhaps undergone necrosis. It could also represent Rathke's cleft cyst or even rarer intrasellar craniopharyngioma....Findings could represent necrotic adenoma or perhaps Rathke's cleft cyst." (I am able to quote only because I obtained full medical record myself.  I was not told what was in the report.  I was only told that pt had a "negative" MRI and that MRI showed a "spot" in his brain that was not unusual because it was "not unusual" for people to have spots in their brains.)  P.M.:  Still has unsteady gait but is able to better balance his trunk. Urine foul so I asked for results of UA and saw 5 ketones in urine.  Blood sugar on 1/08/2010 was 130 drawn before pt had eaten dinner.  Not sure if person drawing lab forgot to draw back some blood first before drawing specimen and this confounded result since IV fluid D 5 ½ NS was ordered at 10 mL/hr and I am not sure if it was infusing at the time.  Pt. had not eaten when lab was drawn; he had been unable to eat for more than 24 hours due to feeling ill and had not eaten yet.     1/10/2010:  11:47 a.m.:  Dr. spoke with my husband and said lesion on my son's brain could be causing his dizziness and blurry vision and lesion would need to be evaluated.  He said he was told that the procedure would involve going through the nose to take out a specimen of the lesion for biopsy (transsphenoidal approach).    P.M.:  Pediatric neurosurgeon spoke with my husband and said lesion needs careful evaluation and spoke with me by phone and said lesion was pituitary cyst and could be surgically removed through the nose as described by my husband if lesion is causing problems for pt.  I informed him of pt's foul urine and blood glucose of 130 and 5 ketones in urine and told him that I wanted pt's urine checked for ketones. (I expected him to write order for this or to at least follow up with the attending.  Later, after obtaining the medical record, I found no evidence that he had done this.)  PM:  Dr. told my husband that they had done all they could for pt and he could be discharged tomorrow morning after they do the transsphenoidal procedure to biopsy the spot in his brain (cyst?).  Dr. also told my husband that people with similar problem like my son do not have abnormal gait like him, so a psychological consult would also be needed for him.      1/11/2010:  P.M.:  My son reported hearing a high-pitched machine sounds in both ears.  Supine BP 87/40, supine HR 53 both by automatic machines.  O2 Saturation 98% on room air.  Big appetite.  Pt said he could feel like the jerking movements were starting to come back.  Shortly after he said this, he jerked twice and told me he thinks that was the last of the jerking.  1/12/2010:  1:22 a.m.:  My son reported hearing high-pitched machine sounds again. I told RN to document this.   8:18 a.m.:  Temp 98.8, BP 93/55 supine; Pulse 62 supine; VERY TIRED.  9:56 a.m.:  Unsteady gait (ataxia).  Headache in the middle of the forehead.  Prior to this, he had always reported only parietal head ache except for one incident of left temple headache which I don't recall exactly when he had the temple headache other than that it occurred around late December, 2009.  Dry non-productive cough. 11:34 a.m.:  Pt. states, "I feel strange, like weak and like I don't have any emotion."  Looks exhausted.  12:02 p.m.:  BP 88/47, P 55, T 98.2.    01/12/2010: Team of physicians agree that patients with pituitary lesions do not have ataxic gait and therefore pt must be experiencing conversion disorder and his problems are not related to the H1N1 vaccine nor the pituitary lesion. Psychiatrist documented that pt. was able to stand up against wall with no problem so his problems must be psychosomatic, thereby he agrees with diagnosis of conversion disorder and says this diagnosis is a diagnosis of exclusion.  I (patient's mother) disagree but physicians overrule me and discharge pt without any treatment and without biopsy of lesion. I was told lesion was benign spot on the brain and was not shown the report results even though my husband and I both had asked to see all tests and results and my husband had asked to see the MRI film itself. I went and obtained patient's complete medical record to create this chronicle  because physicians had withheld information from me. In the evening:  I restarted pt. on Singulair 5 mg p.o.    01/13/2010:  First day of returning to school.  Still dizzy and refused breakfast.  We coaxed him to eat just a few bites.  Complained that both arms hurt in school parking lot and cried and did not want to go to school.  He was calmed by his father and the school nurse.  Is this panic attack?  P.M.:  Poor concentration, tires easily with homework. 01/14/2010:  6:50 p.m.:  Ankle pain. Hobbles.  7:50 p.m.:  Feels hot inside. 01/15/2010:  5:45 a.m.:  Tired, grabs head, dizzy, unsteady gait reappears.  06:15 a.m.:  Exhausted.  Moves very slowly.  10:12 a.m.:  Blurry vision, dizzy, slightly uncoordinated gait.  12:30 P.M. Has jerking movements after he ate lunch. 2:00 P.M.:  Jerking movements totally gone.  Tired from doing homework and skips some questions on homework, which is unlike his usual self.  1/15/2010:  7:50 p.m.:  Feels hot inside.  2:11 P.M.:  Tired.  Calf pain. 1/16/2010:  5:30 p.m.:  Feels hot inside again.  9:14 P.M.:  Left ankle pain, uncoordinated gait due to ankle pain. 01/17/2010: 8:05 a.m.:  Refuses to eat breakfast because he says he feels too hot.  7:40 p.m.:  Feels like burning up inside.  8:03 P.M.:  Insomnia.  8:50 P.M.:  Sweats moderately like his premorbid self. After this, he says he feels better.  01/18/2010:  10:33 a.m.:  Headache, boiling hot sensation inside, cough, coughed up clear mucus, dizzy, slight uncoordinated gait. 11:00 a.m.:  Profuse sweating, no longer feels hot inside, his personality changes back to his normal self like before all the problems started.  11:51 a.m.:  Pt. walked for about 30 minutes in the park, then walked in store for 30 minutes and complained of severe dizziness.  Apical pulse 98 and irregularly irregular.  Exhausted and sleepy even though he had been drinking large amounts of Gatorade-type drink. 1/18/2010:  3:12 p.m.:  Bubbling headache, dry cough, took 2 puffs albuterol inhaler.  Has uncoordinated gait.  Does not feel good. 5:12 P.M.:  Shakes head and looks in pain.  200 mg ibuprofen given.  6:15 P.M.:  Uncoordinated gait, exhausted, dizzy, hot, does not feel good, refuses dinner, coaxed to eat and ate just a few bites. 1/19/2010:  6:05 a.m.:  States he feels "hollow on the inside and outside."  2:35 p.m.:  Moody and angry and scribbled "whacked in head" on paper and would not talk!  It is not like him to not talk to me.  3:05 p.m.:  He yells at me because I ask what happened at school to make him so angry.  He never yells at me, his mother.  4:00 p.m.:  Big appetite.  Wants to eat several hamburgers.  6:30 p.m.:  He calmed down enough to talk to me and told me he was upset a girl had rolled up her paper and whacked him on the head.  I reassure him we will take care of this.  7:58 P.M.:  Big appetite again.  Still taking Singulair, which I had resumed on 1/12/2010 after discharge from the hospital.  8:03 P.M.:  Occasional dry, nonproductive cough; insomnia, hot, dizzy, blurry vision.  11:00 P.M.:  Heavy sweating brings relief.  1/20/2010:  Looks like he has gained weight.  Jerks in cold room.  Appetite continues to be big.  Singulair was discontinued due to behavioral changes.  Tears up easily over little thing like being unable to find his crayon box.  Has insomnia.  Enuresis reappears.  Heavy sweating all over make him feel better.  1/21/2010:  Ankles hurt, especially left ankle.  He says, "When I eat a lot of food and drinks a lot at school, I feel better."  Normal appetite reappears:  He eats a lot normally, but not so much like since he has been hospitalized.  Today, his appetite appears to have returned to his normal premorbid state.  Chiropractic has been helping to make occasional cough improve and improve enuresis. 1/25/2010:  Feels like his eyes are bulging outward, feels dizzy, unsteady gait.  Dry, painful eyes. 1/26/2010:  Still dizzy, cough returns, no enuresis, stuffy nose present.  Had to be absent from school.  Bad cough, insomnia, felt hot inside, dizzy, headache.  I gave him albuterol puffs but cough got worse.  I gave him Children's Triaminic Syrup Day Time Cold and Cough (active ingredients in each 5 mL are dextromethorphan HBr 5 mg and pehnylephrine HCl 2.5 mg).  This brought sudden personality change:  He said he did not feel like doing anything and felt strange and empty inside, like he is just dust.  He also complains of feeling hot and yells at me when I tell him nothing's wrong with him.  1/27/2010:   10:30 a.m.:  I pick him up for a doctor's appointment and he is very sensitive to what others think of him and says he thinks everyone in the class is laughing at him.  This is so unlike him and I do not know why he suddenly develops this irrational sensitivity to others. I reassure him that this is not the case.  6:30 P.M.:  He says he is very hot and not very hungry; eats very little.  6:47 P.M.:  He says he hears screeching sounds when his sister is pointing magic wand at him and laughing and talking.  02/06/2010: Symptoms continue, and on 02/06/2010, pt fainted and was revived by family member. Pulse barely palpable and was 50. Then pt had myoclonic jerks after fainting spell. 02/17/2010: Pt seen in pediatrician's office for follow-up and pediatrician noted pulse still down to 50 beats per minute. Pt complaining of dizziness and headache. Diagnoses: pituitary adenoma, dysautonomia. Plan: Follow up with cardiologist to consider starting florinef. Continue to have follow up with neurosurgeon, ophthalmologist, endocrinologist, neurologists in child neurology.    02/18/10  5:45 pm:  Forgetful:  Had forgotten to do his homework and needed reminders.  He also forgot his book for his reading assignment at school. 02/18/10  7:54 pm:  Received first dose of 0.2 mg Florinef (fludrocortisone) that pediatric cardiologist had prescribed today. 02/19/10:  2:10 pm:  Pt's teacher sent email to me stating that pt had complained of right wrist pain at 1:00, had denied injuring wrist, and had said the pain felt like a bite.  2:50 pm:  There are no signs of bug bites or external injury.  His whole right arm circumference looks approximately the same size as the left arm, although both arms look a little puffy?  I can't be sure of the puffiness.  His legs and arms just look like their diameters had suddenly increased in size overnight.  I can't be sure because I had not measured them. I just reassure him that his right wrist pain will go away.  Pt. denies having any dizziness at all today so far.  He does still complain that his vision is still a little blurry.  He is very revved up and raises his voice and yells a lot at his siblings and makes angry faces at little things.  8:00 pm:  Pt's right wrist is still hurting.  He receives 2nd dose of fludrocortisones today.  10:45 pm:  Pt denies dizziness, but asks me why he is so energetic and feels like he has to jump around.  He is unable to calm down and sleep.   I am concerned that the fludrocortisones is making him act this way.  I talk to his dad and his dad and I feel that it is better to stop the fludrocortisones since we know what triggers pt's previous fainting spell:  delaying food and fluids for a long time.  He had not eaten lunch or drunken anything for about five straight hours on 2/6/10 when he fainted, and his pulse had fallen to 50 on 2/17/10 when he had refused breakfast on that day because he said he was not hungry.  Therefore, we decided it was safer for him to just eat and drink lots of fluids rather than take the fludrocortisone and face its side effects.   2/20/10  3:00 pm:  Denies dizziness. 8:00 pm:  I stopped giving fludrocortisones tonight because of side effects.   2/21/10 6:00 am:  Had enuresis.  This is unusual since he had not been having it for a while since getting regular chiropractor adjustment.  Is it related to the fludrocortisones?  2:50 pm:  Had played tennis for about 1 hour without complaints.  We had made him drink water continually. Then we went jogging. Had dizziness during jogging.  We made him drink continually and dizziness gone.  We decide that patient had been right all along when he had told us a while back that when he eats and drinks, he feels better.  We feel it is better to have pt stay off the fludrocortisone unless he is critically unstable and needs it.  Pt is calmer today.   His feet and legs look puffy and his feet are feel tight in his shoes.   After a jog in the park, the little toes on both feet developed that peeled off from the tight-fitting shoes.  This is unusual since we had just bought this pair of shoes for him in December just before he got the H1N1 vaccine. 2/22/10 7:30 am:  Received chiropractic adjustment. 2/23/10 8:40 a.m.:  Visited endocrinologist who says all hormones are normal and pituitary tumor is coincidental. 2/24/10 7:30 am:  Received chiropractic adjustment.  6:30 pm:  Yashushi complained of head ache and dizziness.  He said his ears felt hot.  I looked and noticed that the middle of both auricles were symmetrically red.  9:00 pm:  Complained of feeling very hot inside and unable to sleep.  The heater was on in his room and the temperature is a little on the cool side but not very cold, so I turned off the heater in his room. 2/25/10 6:00 am:  Ibuprofen given for sore throat the suddenly appears along with cough.  4:15 pm:  Complained of abdominal pain.  I gave him dinner early. 5:53 pm:  Pt still has headache.  He says now he feels like someone is hitting his muscles, but that sometimes the sensation feels like a "gnaw."  7:15 pm:  Sore throat and cough persistent. 2/26/10 6:00 a.m.:  Had enuresis during the night.  SORE THROAT AND COUGH PERSISTENT.  IBUPROFEN GIVEN.   Also has CLEAR NASAL DRAINAGE.  9:21 A.M.:  Cough and sore throat improved.  Complains of itching all over.  Had just eaten scrambled eggs seasoned with just salt and some rice with water.  He has eaten this throughout his life with no problems, so I do not know what is causing the itch.  I told him to apply lotion to his body. 2/27/10 5:45 PM:  Pt has just finished  swimming with the family. He covers his left eye and looks uncomfortable.  He says that there is "something solid in my eye" and keeps squinting and covering that eye.  His dad and I reassure him that it is probably the chlorine in the pool water bothering his eye. Pt also looked exhausted and had grayish bags under his eyes, so we returned home instead of going to the movies as we had planned.  7:45 pm:  No relief from left eye discomfort.  I apply lubricating eye drops. 2/28/10 12:15 pm:  No more complaints of left eye pain, but pt looks exhausted after just 15 minutes of playing tennis.  He had played tennis last week on 2/21/2010 without complaints, so this is unusual.  We therefore cut the tennis game short and headed for swimming in the heated pool since swimming is more gentle on patient's joints and we thought he could just walk and float in the pool without getting overly exerted.  3:30 pm:  Pt walked, floated, and swam in the heated pool for approximately 1 hour.  Then we left and as we were walking in the parking lot, the wind blew fiercely and it was very cold.  Pt did not have the hood of his jacket covering his head.  He suddently complained that he was not feeling well, that he was feeling weak and dizzy.  He looked exhausted and walked with haunched shoulders in the parking lot.  His dad and I had to walk close to him so if he falls, we could catch him. We kept encouraging him to keep being strong and to drink a lot.  He drank a lot and we went to the mall to buy food because the last time he had eaten was about 11 a.m., so we thought he might be feeling weak because he was hungry, too.  5:00 pm:  There was a long delay in traffic so we did not get to the mall until late in the afternoon and pt  did not get to eat until now. He looks exhausted and his back is hunched over.  He is unable to stand in line to order food.  His dad and I walk him over to the dining table and let him sit down instead of standing in line to order food.  We brought the food over to him.  5:45 pm:  Pt's facial expression looks more alert and brighter and less exhausted.  We continue to have him drink lots of water. 3/1/10  7:45 a.m.:  Received chiropractic adjustment.  7:45 p.m.:  PT SAYS HE FELT DIZZY WHILE RUNNING AT SCHOOL TODAY.  ALSO COMPLAINS THAT HIS BONES HURT INSIDE AND IT IS NOT JUST THE MUSCLES HURTING NOW. 3/2/10 5:33 PM:  Pt says he FEELS LIKE HIS BODY IS BREAKING OUT IN GOOSEBUMPS and asks me if his skin looks like it is doing this.  I tell him that I do not notice any goose bumps because I indeed do not see any.  I feel his skin and do not feel any goose bumps.  However, it is snowing heavily and very cold, so I think this temperature extreme and change in the weather is triggering this abnormal phenomenon he is experiencing.  I tell him to go put on his coat because he is just wearing a short-sleeved sheet.    3/3/10 5:47 a.m.:  COMPLAIN OF SEVERE PAIN TO BONE AND MUSCLE.   Grimacing and hunched over.  I made him get out of bed and made him get dressed, but he was getting dressed so slowly that I became concerned.  200 mg ibuprofen was administered to him to relieve pain and he was told to eat breakfast.  6:00 AM:  THE PAIN WAS SO SEVERE HE COULD NOT FEED HIMSELF.   8:10 AM:  PT ABLE TO WALK AGAIN, BUT WITH SLIGHT HUNCHED SHOULDER AND SLIGHT HOBBLE.  3:45 PM:  ABLE TO WALK NORMALLY AGAIN. Follow-up: 04/08/2010: 8 a.m.: Received physical therapy where he was made to exercise vigorously for 10 minutes. Systolic BP immediately after exercising was 95. 9 a.m. Yawning but denied having problems. 10 a.m. Still able to walk but felt he needed to use wheel chair, so pt in wheel chair. 11:27 a.m. Unable to walk without assistance. Sitting in the back seat of the care en route to received hyperbaric oxygen therapy (HBOT). Became lethargic in back seat of car, unable to chew, swallow, or hold up arms and head. Head became floppy. Mirthful facial expression that lasted approximately 15 minutes. Then patient suddenly awoke and was disoriented to where he was