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CASE 1. 49 year-old female was in good health until July 2003 when she developed a severe flu-like illness. The patient was living in Incline village, Lake Tahoe for 14 months. The patient had low-grade fever, chills, myalgia, severe throat swelling followed by neck pain, without sinus congestion, cough, chest pain, headache or diarrhea. Physical examination after one week of illness demonstrated neck tenderness. A complete blood count, comprehensive chemistry panel, thyroid function test and erythrocyte sedimentation rate were normal The patient was told to have either a viral infection or lupus. CT scan of the brain and spinal tap performed for the severe headache did not reveal any findings. Chest x-ray was negative. Treatment with Medrol dose pack and Celebrex did not alleviate her symptoms, except the neck pain improved to some extent. The symptoms of acute illness lasted about several weeks but the fatigue and neck pain never resolved. The patient subsequent had relapsing symptoms of fatigue, myalgia, low-grade fevers, night sweats, sore throat and cervical lymphadenopathy, cognitive dysfunction and debilitating headache. The patient received Medrol dose pack 4 different times since the beginning of the illness. The illness spontaneously cycled every week with one good day at an energy level of 6/10 and 1-3 bad days a week with energy level of 2-4/10. She could not concentrate and had severe post-exertional fatigue for 2-3 days. She had been depressed and crying a lot. The patient was only able to work 20 hours a week, but had severe fatigue after work requiring extra hours of sleep at night and on weekends to build up enough energy for work. She woke up quite often especially when she was more tired. The maximal exercise she can perform now is walking one block whereas she could swim and ski before he became ill. She would need to take a nap frequently. She has gained 20 lbs in one year. Afterwards, she had to quit her job due to increasing fatigue. IgG antibody to Epstein-Barr virus and CMV were minimally elevated, but the IgM antibody was negative. C. pneumoniae IgG was 1:8. Antibody titers for coxsackievirus B1-6 and echoviruses 6,7,9,11,30 were not significantly elevated. Physical examination mild throat inflammation, minimal, tender anterior neck lymph nodes. Significant epigastric and right lower quadrant tenderness. Diffuse muscles tenderness Laboratory investigation: low level of enteroviral RNA was detected in the whole blood. Staining of stomach biopsy showed extensive enteroviral protein (as shown, 100x magnification).  She tolerated the combination of alpha and gamma interferon poorly. Subsequently, she was treated with IVIG every 3 months with mild improvement. Assessment & Treatment: Chronic fatigue syndrome the patient’s symptoms started in the summer of 2003 following a flu-like illness. The nature of the illness was highly suggestive of enteroviral infection. Incline village, the place where the infection was acquired had a major epidemic of CFS/ME in 1984, and the etiology was never elucidated by the CDC investigators. However, lake water is known to have enteroviruses. The patient has fulfilled the 2 major and 4 minor criteria for the diagnosis of CFS, as established by the CDC in 1994. The results of the serological study were not diagnostic for acute EBV, CMV or enterovirus infections. The major drawback of the serological testing is that neutralizing antibody tests are only available for 11 of 70+ non-polio enteroviruses. However, enterovirus RNA was detected in the blood and the staining of the stomach biopsies demonstrated extensive viral protein few years after the initial infection, consistent with chronic enterovirus infection . The use of medrol dose pack during the acute phase of infection most likely shifted the immune response to the Th2 (T helper 2) direction, which allow the viruses to persist in the body. She has mild to modest improvement with IVIG infusion given every 3 months. CASE 2. 36-year-old white male who had been in remarkable health until December 2004 when he had self-limited nausea and vomiting, followed by mild fatigue and myalgia. He used to run 6 miles every other day but had to cut back over the next several months. In April 2005, the patient had sudden onset of vertigo, nausea and vomiting, then had dizziness, headache and nausea two weeks later. In July 2005, the patient had severe diarrhea, nausea, dizziness, blurred vision, cross-eyed feeling, dysequilibrium, flu-like symptoms and post nasal drip. By the next month the patient had severe pain between the eyes, daily dizziness along with other symptoms. In November/December the post nasal drip improved. The patient had upper stomach pain and was found to have a gall bladder polyp by ultrasound. The patient had GERD, Gastro Esophageal Reflex Disease, along with other symptoms. The patient had a number of emergency room visits for severe GERD symptoms. Eventually a gastric-emptying study showed gastroparesis of the antrum. In May 2006 the patient had diffuse muscle fasciculations and numbness of his hands and feet, sharp jerking shooting pain all over the body. In June 2006 the patient had a spinal tap that was completely normal. Lyme’s disease antibody was borderline positive although the patient had never been in the areas endemic for Lyme’s disease. An Infectious Disease physician felt the patient did not have active Lyme’s disease. In the fall of 2006 the patient had a tilt test that showed postural orthostatic tachycardia. The patient was given atenolol and felt much worse. The patient has not worked since September 2006. Eventually the patient was treated with 6 months of intravenous Rocephin for Lyme’s disease without improvement of his symptoms. EBV and CMV IgG were positive. All the regular blood test results including CBC, chemistry panel, TFT, CT scan, MRI scan, EMG continued to be normal. The patient was given Valcyte for 3 months without benefit. Subsequent MRI scan done showed a punctate white lesion on the surface of the left parietal lobe which was not confirmed on a repeat MRI scan done six months later. Energy level was better for 3 out of 7 days but he could only do 3 hours of light activity with frequent breaks. On the other 4 days the patient was practically bedridden with energy level 0-1/10. He continues to have numbness, stabbing pain in the fingers and toes especially when he sits down, along with neck stiffness. Routine laboratory studies including TFT, ANA, RF, CRP, ESR, H. pylori antibody. Lyme’s disease antibody done at Stoney Brook Laboratory, celiac disease panel, urine heavy metal screening, SS-A, SS-B antibodies were negative. AST and ALT were mildly elevated on two determinations. CSF, MS panel on June 3, 2006 was negative. CT of the sinus showed small polyps within the maxillary sinuses. ENG and hearing test were normal. EGD and colonoscopy in January 2006 showed a single sigmoid polyp. Stool studies were negative. The patient was treated with tapering course of prednisone in November 2005. In June 2008, CVB 4 antibody titer was 1:640 (<1:10). PHYSICAL EXAMINATION: The patient does not look sick. Throat- 2+ throat inflammation. Neck minimal, tender lymph nodes, mildly tendery. Abdomen mild epigastric, lower quadrant tenderness. Extremities- no muscle tenderness. Neurological normal. Special laboratory tests done at EV Med Research: Blood positive for 355 copies/ml of EV RNA. Stomach antrum biopsy showed extensive enterovirus protein (as shown, 400 x magnification).  ASSESSMENT: Chronic fatigue syndrome with documented orthostatic hypotension, chronic dizziness and other neurological symptoms, was most likely due to a chronic enterovirus infection since the initial symptoms of infection were gastrointestinal. These viruses would enter through the GI tract by eating contaminated food or drinking water, then disseminate to the brain, spinal cord, muscles and heart, most often through the blood but sometimes in a retrograde manner through the nerve fibers, as has been documented with enterovirus 71. The brain stem symptoms and orthostatic hypertension are all suggestive of viral infection in those areas, but the lesions are probably too small to be seen by the usual imaging studies such as CT and MRI scans. It is interesting that there is a lag time of several months between the initial GI symptoms and the subsequent brain symptoms. This is actually typical of many of the patients who did not have flu-like symptoms immediately before the onset of the CNS or muscles symptoms. The best explanation is that viruses disseminated to the secondary sites, such as brain may not manifest until the initial immune response gradually subsides. Although the diagnosis of Lyme’s disease has been implicated in the endemic areas by a few investigators, this patient was never in the endemic areas for Borrelia burgdorferi., and the final serology done in a reputable laboratory showed totally negative results. Furthermore, the continuing GI symptoms or even respiratory symptoms in other patients are inconsistent with Lyme’s disease, since this infection is transmitted by a tick bite and dissemination has been documented in the joints, heart and the brain. The lack of response to valcyte is not surprising since the drug is used for herpes viruses and yet the patient has an enterovirus infection. The treatment for orthostatic hypotension is not ideal. Many of the patients did not tolerate beta blocker. Alternatively, midodrine starting at 2.5 mg t.i.d. then work up to 5 mg t.i.d. and increase further as tolerated, may be helpful for some patients. Antiviral therapy is still the key to control enterovirus infection, which will require development. CASE 3. 15-year-old white male had recurrent upper respiratory tract infection since early childhood. The patient developed asthma and was treated with steroids at least 3 or 4 times over the years. He was able to play soccer but would have at least a brief relapse with symptoms of coughing, sore throat and fatigue for 7-10 days after playing in a tournament. He was functional until September 2007 when he had bedridden fatigue, global headache, sore throat, insomnia, sinus congestion and persistent cough after another episode of respiratory infections. The symptoms did not respond to antibiotics or Elavil. The results of EBV and CMV antibodies were consistent with prior infection. DNA test for CMV and EBV and Lyme’s disease antibody were negative. Thyroid function tests, CBC, chemistry panel were all normal or negative. The patient was evaluated by other physicians who all concluded that the patient had a diagnosis of pediatric chronic fatigue syndrome and subclass IgG deficiency. Immunologic workup by an immunologist showed a B-cell dysfunction in that there is deficient memory for immunoglobulin production. Immunization with pneumococcus vaccine and HIB showed a positive antibody response which declined at six months. He actually was started on IVIG but had a reaction to the specific preparation of IVIG. The patient was treated with numerous antibiotics Biaxin, Augmentin, Cipro and Zithromax but experienced questionable improvement. Sinus CT scan showed extensive inflammatory changes but no air-fluid level. Previous cultures of sinus drainage have all been negative. Intravenous antibiotics did not help his symptoms. The patient also had upper stomach pain, nausea, fullness after eating, diarrhea at least one time per week. He underwent a colonoscopy and EGD with biopsy on February 14, 2007. Multiple biopsies of the esophagus, stomach, duodenum, terminal ileum and various parts of the colon showed minimal inflammation but with prominent lymphoid aggregates in practically every biopsy. The patient has not been able to attend school and could not participate in competitive soccer and is basically homebound. He continues to have all the above symptoms of headache, bedridden fatigue, mild myalgia. Laboratory studies showed Coxsackie B-4 antibody of 1:160, echovirus antibodies were negative. CMV IgG, IgM are now negative. IgG subclass-3 is still low at 32. HHV-6 antibody was 1:160. PHYSICAL EXAMINATION: Sinuses - mildly tender. Throat mildly inflamed without ulceration, thrush. Neck minimal lymph nodes. Abdomen - mild epigastric and right lower quadrant tenderness. There is minimal muscle tenderness over the upper and lower extremities. Neurological - looks somewhat tired but otherwise normal. ASSESSMENT & TREATMENT: Chronic fatigue syndrome in a pediatric patient with B-cell dysfunction, low IgG1, IgG3 levels. The patient had frequent respiratory infections since childhood complicated by asthma. The patient likely has a Th2-dominant response which could not eradicate viruses that become persistent in his body. Instead of having numerous new infections, most of the episodes of the sinusitis were likely reactivation of the underlying viral pathogen. This type of patient most likely has enteroviruses especially in view of the respiratory and the GI involvement. The fatigue did not increase until later when he acquired another unique strain of enterovirus. There was likely a significant shift of the T-cell response downward to allow reactivation of underlying pathogens. The antibodies for Coxsackie B viruses and echoviruses (5/26 serotypes) were not significantly elevated. The biopsies from his stomach and colon tested positive for enterovirus VP 1 protein, a more specific indicator of persistent infection. Epigastric and right lower quadrant tenderness elicited by physical examinations correlated well with finding of enterovirus protein in the stomach biopsies, and therefore is a valuable sign to document in ME/CFS patients. The patient was started back on another preparation of IVIG, which he tolerated well. He had improvement of the sinus symptoms but remained quite fatigued. CASE 4. 42-year-old white male who developed a viral illness in 1986 that lasted at least one year. The nature of the illness was an upper respiratory infection associated with weakness, drowsiness, fatigue, sniffles, postnasal drip, dizziness and some weight gain. He did have purulent sputum, which was treated with antibiotics, but the patient continued to have significant respiratory congestion. Sinequan did help the insomnia and his energy level. He essentially recovered in October 1987. The symptoms recurred in April 2003. The episode lasted at least two months, started off with sinus infection then profound fatigue. He eventually recovered but still felt somewhat sluggish for several months. In September 2003 the fatigue recurred with swollen left eyelid but did not have any significant eye disease by examination. The fatigue actually improved after a cortisone shot followed by Medrol dosepak. The patient went back to work and yet the symptoms recurred in late December associated with insomnia and GI upset but no diarrhea. EGD and colonoscopy in January in 2004 showed no significant abnormalities. Biopsy of the stomach showed minimal inflammatory changes. The patient could not get out of bed on most days. He had occasional night sweats associated with increased fatigue, intense myalgia (muscle soreness), mild cognitive dysfunction, post-exertional malaise and unrefreshing sleep. Previous laboratory testing was essentially normal except for intermittent elevated liver enzyme to 65 (normal <40) in March 2003. Review of his blood work showed negative rheumatoid factor, anti-nuclear antibody, erythrocyte sedimentation rate. Repeat testing in September 2003 showed EBV VCA IgG of 47, negative IgM; normal CBC. Previous sinus CT on September 8, 2003 showed some paranasal sinus disease and a cyst in the right maxillary sinus. ALT was elevated at 61 in January 2004 but other aspects of the chemistry panel, CBC, TSH were again normal. Coxsackievirus B1-6 and Echovirus 6,79,11,30 antibody titers were negative. PHYSICAL EXAMINATION: The patient looked mildly fatigued; not depressed. Vital signs normal. The general examination was normal except for minimal throat erythema, minimally tender cervical lymph nodes and moderate tenderness of the epigastrium, right lower and left lower abdomen. No muscle tenderness or trigger points were demonstrated. Stomach biopsy done in 2004 was positive for enterovirus protein when performed in 2007. ASSESSMENT & TREATMENT: Chronic recurrent fatigue began as an initial episode in 1986 lasting one year. The nature of the infection was not typical of EBV infection and the low EBV antibody was consistent with this assessment. Acute EBV infection, or acute mononucleosis, does not present with nasal or sinus congestion, rhinorrhea. This initial virus infection was probably enterovirus since other respiratory viruses, such as adenoviruses, coronaviruses, influenza, parainfluenza, RSV or metapneumovirus typically would not cause symptoms in immunocompetent patients for more than few weeks. The symptoms recurred few times over the next 20 years, mostly brought on by another respiratory infection. The GI symptoms were largely dismissed as irritable bowel syndrome and treated symptomatically. The stomach symptoms, such as nausea, indigestion, acid reflux, bloating with or without meals are suggestive of chronic enterovirus infection, which was confirmed by enteroviral staining of his stomach biopsy when the technique was developed. The patient was treated with a combination of alpha and gamma interferon for one month and went into remission for about one and a half years. CASE 5. A 29-year-old white female developed recurrent sinus infection and severe vomiting during her second pregnancy 6 years earlier, though she did not have any difficulty with her first pregnancy. However, she had vomiting again in her third pregnancy two years later and continued to have recurrent sinus congestion. In June 2004, the patient developed sore throat and right cervical lymphadenopathy, lower abdominal pain, increasing nausea, sinus congestion. The patient did not have any diarrhea. The patient was given amoxicillin with resolution of the sore throat in 5 days. The patient has been tired ever since. Initially her energy level was as low as 3/10 with pain over the neck, shoulder, arm and increasing migraine headache. She did have mild night sweats, mild brain fog only with the headache. The sinus congestion would worsen with her worst days. In general, energy level has improved in the last year and a half. Now her energy level is about 5-6/10 but she still feels bad with a level of 3-4/10 at least twice a month. The patient does not do exercise but is very busy taking care of three kids. Recent laboratory studies done on November 9, 2005 showed normal CBC, chemistry panel, UA, HbA1C, TSH, ESR. EBV VCA IgG was 160 (normal <90) with a negative IgM. CMV IgM was 1.4 (0-0.8). CVB antibody was 1:32-1:64 by CF method. The patient has frequent nausea especially at night, diffuse myalgia. Coxsackievirus B3 antibody and echovirus antibody titers were 1:80 and 1:160, respectively. PAST MEDICAL HISTORY: Hiatal hernia and probable IBS; had EGD/colonoscopy that showed mild inflammation in the antrum. PHYSICAL EXAMINATION: Throat red patches over throat. Abdomen- tender over epigastrium, both lower quadrants. Extremities tender over all the muscle groups. Neurological normal. Stomach biopsies done in 2006 showed extensive viral protein staining (100 x magnification) and tested positive enterovirus RNA.  ASSESSMENT: Chronic fatigue syndrome that started with one enterovirus infection that dated back to sinus/GI infection during her second pregnancy. This is likely enterovirus infection due to the nature of the symptoms. However, the infection was not eradicated during pregnancy since the immune system was likely shifted to a Th2-dominant response. The patient did have an endoscopy 1 1/2 years earlier, and a biopsy tested positive for enteroviral protein and viral RNA. The patient responded to Chinese herbs. CASE 6. 43-year-old white female developed right lower quadrant abdominal pain and constipation in June 2005, when she was training for marathon. The pain was quite severe and lasted about a week. CT scan of the abdomen and pelvis was negative. She rested at home and then went back to work. On July 4th the patient developed recurrent right lower quadrant pain after she had a big feast. She had severe diarrhea. The patient had a colonoscopy, which was essentially normal by biopsy. The patient was subsequently discharged although the diarrhea continued in September. Capsule endoscopy was negative. The patient was given antibiotics without much response. EGD was not done. The patient continued to have a severe sore throat. The patient had low-grade temperature from 100F to 101F along with night sweats, fatigue, diffuse joint pain and myalgia of the right lower extremity. In January 2006, the patient had significant sore throat, lymphadenopathy. The patient was given antibiotic with subsequent increase in diarrhea. The patient developed increasing night sweats, fatigue, insomnia, irregular menstrual period. Hormonal tests were normal in February 2006. The patient also had right hip joint pain and had significant increase in blood pressure without documented renal disease. The patient was placed on antihypertensive medication with improvement of the blood pressure. The patient traveled all over Asia for many years. The patient did develop diarrhea around 2000 or 2001 which lasted for a few months, which recurred a few times every few weeks. The patient had increased allergic rhinitis and sinus congestion. In 2005, between January and June, the patient was training for a marathon before the increase in symptoms. At the present time, the patient could not function for more than 1-2 hours /day before having to lie down. She continued to have low-grade fever and some night sweats, difficulty with mental concentration, fatigue, unrefreshing sleep, nausea and indigestion. Energy level was about 3-4/10 and 8/10 in 1/30 good day. The patient would crash the next day after a good day. PHYSICAL EXAMINATION: Throat: minimal redness. Neck: minimal anterior and posterior cervical lymph nodes without thyroid enlargement. Abdomen: epigastric and right lower quadrant tenderness. Extremities: mild muscle tenderness, without edema, clubbing or cyanosis. Neurological unremarkable. Enterovirus staining of the stomach biopsies showed extensive VP1 staining (magnification 100x)  ASSESSMENT: Chronic fatigue syndrome with prior gastrointestinal illness. The patient had prior episodes of diarrhea back in 2000/2001 after she traveled to Asia, which raised suspicion of enterovirus infection. In 2005, between January and June, it was possible that the increase in physical exercise resulted in the relapse of this chronic enterovirus infection. Within one month she responded to Chinese herbs, and continued to take these herbs for more than 1 1/2 years. Energy level is now 8/10 most of the time with only few bad days (5/10) before her periods. CASE 7. A 17-year-old white male had frequent infections as a child. The patient experienced sore throats at least 1-2 times a year, and then developed asthma at age 7, which was treated with inhalers. He started feeling tired along with experiencing thigh and leg pain since about 4-5 years ago. The patient recalled he and his brother became ill with vomiting, diarrhea, abdominal pain after eating at a local Mexican restaurant. The parents did not get sick. The patient was hospitalized for one day and sometime later developed fatigue, difficulty with concentration, deep pressure-like headaches along with nausea and indigestion, but no sore throat. His energy level has been about 3/10. The patient could go to school from 8:00AM to 3:00PM, but after school falls asleep for a long time and sometimes sleeps till the next morning. The brother also developed intermittent epigastric pain and mild fatigue. Laboratory studies included repeated complete blood counts and chemistry panels in February and March 2008, which showed normal results. IgG level, IgA level, TSH, FSH, T4, testosterone levels were also normal. ANA, ESR, RF were negative with a normal CH-50. A rheumatologist felt the patient did have fibromyalgia. The patient was treated with Elavil and Neurontin with mild improvement. The patient did not respond to bio-feedback/hypnosis. He was found to be allergic to cat and dog danders, olive trees, etc. Six months ago the patient developed symptoms of viral meningitis which were treated symptomatically as an outpatient. After this episode, the patient developed marked increase in fatigue, postexertional malaise, poor sleep with frequent awakening at night. He did have night sweats, mild arthralgia along with the myalgia, but no rashes. His grades worsened with increasing cognitive dysfunction. The patient did see Dr. St. Amand who felt the patient had fibromyalgia, but a 6-month course of guaifenesin did not help his symptoms. The patient has tried Soma and Flexeril which made him more tired. PAST MEDICAL HISTORY: Acute mononucleosis 2 years ago. PHYSICAL EXAMINATION: Sinuses non-tender. Nostrils minimally inflamed. Ears normal. Mouth 0.7 x 0.7 centimeter follicular erythematous swelling over the oropharynx. No other ulceration, thrush. Neck: shotty AC/PC lymph nodes, mildly tender; no thyromegaly. Lungs and heart normal. Abdomen: mild but significant epigastric and right lower quadrant tenderness. Extremities: without edema, clubbing or cyanosis; minimally tender over the upper and lower extremities. Neurological: the patient does look tired but able to sit on the examination table most of the time. Cranial nerves II-XII within normal limits. Motor strength equal on both sides. Reflexes normal. Gait, Romberg negative. Stomach biopsy showed extensive enteroviral protein by staining. ASSESSMENT & TREATMENT: Chronic fatigue syndrome following repeated virus infection. At age 7 the patient developed asthma following virus infection which is indicative of th2 response. 4 or 5 years ago the patient developed vomiting and diarrhea after eating Mexican food which was followed by fatigue, myalgia, CNS dysfunction, etc. The GI involvement and other symptoms of CFS are highly suggestive of chronic enterovirus infection, which worsened after developing viral meningitis six months ago. The most common agent causing viral meningitis is enterovirus. After repeated enterovirus infections, the patient seemed to do much worse. The patient had minimal improvement of symptoms after IVIG, but now doing much better on oxymatrine, a Chinese herbal supplement. CASE 8. A 44 year-old female experienced a great deal of stress in 2000 when she worked as a teacher and assistant principle. She became more depressed and did not respond to anti-depressant. The patient was already fatigued, but did not seek medical help during her busy summer schedule. Myalgia and arthralgia started mainly in hands, wrists and muscles around the joints, which were migratory in nature. She noticed pain and spasms over her neck and both shoulders. The patient did not have fever, but did have mild chills and mild night sweats. She had unrefreshing sleep, cervical lymphadenopathy, sinus congestion, pharyngitis, chest pain, headache, diarrhea and severe fatigue. A medical evaluation revealed shoddy cervical lymph nodes and diffuse muscle tenderness (trigger points). She was felt to have depression and fibromyalgia. A complete blood count, comprehensive chemistry panel, thyroid function test and erythrocyte sedimentation rate were normal and a work-up for autoimmune diseases was negative. IgG antibody to Epstein-Barr virus was positive with a negative IgM antibody. Treatment with Paxil did not alleviate her symptoms. She had frequent dizziness, unsteady gait and tingling of her hands. For the work-up of her abdominal complaints, EDG did show mild gastritis, which responded to Prilosec. A colonoscopic examination was negative. Second rheumatology evaluation confirmed the diagnosis of fibromyalgia. The patient was treated with Ultram, Klonopin, Celexa, Trazadone, which did help the pain, sleep and depression. However, the fatigue continued. The patient tried Guaifenesin in the summer of 2002, but did not improve and experienced an increase of symptoms. After she traveled to the east coast of the U.S., the symptoms of fatigue, myalgia worsened for 6 weeks. The symptoms would fluctuate every week, severe fatigue would last several days with energy level of 1-2/10, then gradually improve to a level of 4/10 on her best days. The patient had to quit working after one year of illness. The patient had to have a wheelchair to get around the house after she got back from her trip. All of the muscles and joints hurt after she performed trivial activity. Now, the maximal exercise she can perform is walking slowly for 15 minutes with post-exertional malaise whereas she could jog for miles. Before she became ill she would rarely need to take a nap, wheras now she must lie down very often. She slept poorly, awakening q 3 hours. Even doing her hair will make her tired. She lost 10 pounds since the onset of illness. The symptoms were much worse right before her periods. She would have 5 good days in a month.
Past Medical History. Physical Examination: Throat is mildly inflamed. Mildly tender neck lymph nodes. Adomen: Moderate epigastrium and lower quadrant tenderness. Neurological: Lying down on the examination table the whole time. Not grossly depressed. Normal examination except for slow response to questions and poor memory.
Special laboratory study:
Assessment & Treatment: |
