Age: 11.0
Sex: M
Vaccine: HEP
Symptoms: Headache, Hemiparesis, Hyperventilation, Muscle spasms, Myalgia
Clinical narrative: CFS, Heart palpitations, muscle soreness, headaches, dizziness, spasms, cognitive dysfunction, stomach cramping, trunk rash, night sweats, weakness in knees. Treatment: IV with antibiotic & VHC, Sauna therapy, Bio-Ray Light Therapy, Low Glycemic Diet. More treatments may be needed. The 60 day follow-up states that the pt continues to have light headedness, cognetive issues, stomach problems, sleepin gissues, cold/hot sweats. Some symptoms have improved but he is not the same child as before the shot. The follow up received on 6/13/01 states at the end of January 2001, pt had a flu-liek illness associated with headache and fever. This lasted approximately two weeks. Approximately one day after the fever stopped, he received a  hep B shot, which the mother is concerned may be related to his symptoms. He was better for a few days and then he had another flu-like illness for approximately two weeks. He has had intermittent stomachache, no vomiting, occasional headache a few times per week, and no joint pain. For the past two days he has had a rash, however, this has been in an area where his bathing suit is located and he has been in a hot tub over the weekend. The family is concerned because pt has episodes where he is shaky, dizzy, nauseated, lightheaded, and notices numbness around his mouth and hands associated with hypertension. He has had several of these "attacks." Once was at a movie theater and there have been a number of these episodes over the past few weeks. The first episode occurred on 2/16/01. He has been on home hospital schooling for the past two months. There have been a significant number of psychosocial stressors in the house. The parents are in counseling at this time and pt attended his first counseling session 3/2/01; however, it was presented to him that he would be attending family counseling in the middle of February. Pt has a history of irritable bowel syndrome and a history of chest pains, which I have noted in his old medical records. Pt has had a holter monitor, an EKG, a chest x-ray, and numerous lab studies which all have been unremarkable other than intermittent low white blood count. The family provided me with a video today, which demonstrates pt in a hot tub, pt jumping on a trampoline, having fun with his father, and then an episode of one of his "attacks." The video demonstrates pt hyperventilating with some generalized shakiness and he is quite alert and repsonding to his father's numerous questions regarding his symptoms. The overall impression of the video tape is that these episode is psychogenic in origin. While watching this video in the office today, pt began to have another one of his episodes with generalized tremulousness associated with heavy breathing. This lasted approximately one minute. The parents in retrospect note that upon suggestion pt seems to be able to resolve these episodes. A follow-up visit has not been set up at this time, but I would be happy to see pt back at any time if I can be of further assistance. The mother questioned whether further work-up was necessary. I do not feel that any further work-up is needed at this time. However, because the mother is somewhat concerned about this, I have reassured her that there is no identifiable illness that needs treatment immediately and after two months of intensive psychological help, if pt is still having significant symptoms or is worsening at that point I would consider further work-up. Often, medicalizing such illness can worsen the problem and I have emphasized this to the family as well."