Age: 20.0
Sex: M
Vaccine: ANTH, HEP, ANTH
Symptoms: Abdominal pain, Dehydration, Gastrointestinal disorder, Nausea, Pain
Clinical narrative: 1/11/03 - Anthrax shot 1. 1/17 & 1/18 - pale looking and tired 1/22 - tired. 1/25/03 - Anthrax shot 2. Started not going to the gym every day; extremely tired; going to bed earlier and sleeping late; did PT in patient's room - sit-ups, pushups, and extremely tired afterwards. 2/8/03 - Anthrax shot 3. Feb 9 - could not pass any of his PT test and could not understand why; after PT test, he felt sick for several hours; very tired, small appetite. Feb 11 - 4 p.m. extremely tired; 6:30 to 7:00 - no appetite - drank a cup of water and threw it up; 9 p.m. he tried to eat and regurgitated again; abdominal pain throughout the night; every hr to 2 hrs he threw up; gagging; 2 times he had a normal bowel movement. 2/12 - drank cranberry juice in the morning and at 10 a.m. he threw it up; called for an appmt for 13:30 at a local health center; abdominal pain; at 13:30 he went to clinic - he was dehydrated enough they put him on an IV; he also had a slight temperature and constant dull abdominal pain; given Fedradine pain killer; urine test showed that he was dehydrated; blood test was taken and WBC was high at 15; the health clinic sent him to ER at another hospital for possible appendix problem; a CAT scan was done it showed the appendix was ok but there was inflamation in the bowel - small intestine. Had nothing to eat. 2/13 - in hispital - 2 antibiotics were given and his WBC started to go down; tired all day; nothing to eat; no pain except when MD's pushed on his abdomen (both right & left side); drank 1 gallon of golytly to clean him out for the colonoscopy to be done the next morning on 2/14. Feb 14 - had colonoscopy done, came back to the room and slept, felt fine, ate dinner and drank 3 glasses of juice; went home for several days. Feb 15 - tired. Feb 16 - tired; body aches. Feb 17 - tired; helped his dad shovel snow; came inside and slept. Feb 18 - tired; helped his dad w/the snow, came inside & slept; it hurts to squat. Feb 19 - back to school; tired. 2/20 - 1st time he played his French Horn for a week and he felt pain and stress in abdomen; tired again 2/21 - Barium follow thru (x-ray) taken and went back home. Feb 22 - tired; c/o being tired all wknd. 2/23 - tired again, knee felt weird, gave out twice, no energy; 2/26 - knee gave out again; teacher noticed he was not himself. 2/27 - tired and was late for class (and he's always early); 3 abdominal attacks - had to leave 2 of his classes due to vomiting. 2/28 - tired; 7:30 p.m. he was extremely tired so he lay down for awhile then he was ok until 11 p.m. when he went to bed and slept til 10 a.m. (slept in late, even though he usually gets up very early). 3/1/03 - got up at 10 a.m. tried to run to a concert and was exhausted afterwards - he almost fell asleep at the concert. 3/2 - very tired; several attacks - going to the bathroom and throwing up again. Since Feb 11, all he can do is short job and he becomes very tired and he can hear and feel his belly move and it causes pain. 60 day follow up states pt has not recovered. Recent CAT scan of the abdomen showed continued inflammation of the bowel. Continues and have abdominal cramping. Started new medication- entocort EC and having good success with Rx. Has deminshed abdominal cramp and enabled member to participate in sorts and other activities. Currently on Reglan, Bentyl and Entocort EC