Previous Hospitalizations/Surgeries:Appendectomy (age 14, performed while inmate at Federal Juvenile Detention Center); red ward (1 wk, age 16)
Encounter Notes:
Patient is 16yo male presenting for well child exam. No complaints today, no concerns. Recent treatment for moderate protein malnutrition and recent acute magic viral infection, now chronic carrier. Recovering well. Gaining weight appropriately. Reports greater independence and increased exercise capacity. Reports mood is good—interactive and engaging during clinic visit. Patient heart rate, blood pressure, temp all within normal range (HR 72, RR 16, BP 110/65, T 37C). Ordered routine blood tests.
Diagnoses:Primary:Well patient;Secondary:None
DATE: 6 May 2123
PHYSICIAN’S NOTE: Evaluation of fever, chills, joint pain.
Name: Shirazi, Dara
DOB:25 October 2104
Address:c/o Minister Calix Lehrer, Apt. 13, Carolinia Government Complex. Blackwell St., Durham, CAR
Citizenship:Republic of Carolinia
Parents or Legal Guardian:Over 18
Blood Type:O-
Status:Witching;Antibody titer:Present at 1:2;Presenting power:Telepathy
Height:5’ 9”Weight:[unknown; patient refused]
Problem List:History of ventricular arrhythmia secondary to severe metabolic derangements (hypokalemia); iron-deficient anemia due to malnutrition
Previous Hospitalizations/Surgeries:red ward (2 wks, age 4); laceration repair (performed magically by CL) and intentional overdose requiring ICU hospitalization (age 16)
Encounter Notes:Consultation on request of C. Lehrer. Pt is an 18yo male. Generally resistant to providing history so information obtained from his father, CL. Father brings in pt due to fevers, joint pain and excessive fatigue, concern for acute viral intoxication syndrome. No history of viral intoxication syndrome in the past. Age of primary infection: 4, ab titer: 1:2. Pt enrolled in Level IV—typical daily magic expenditure substantial at baseline but father reports recent drastic increase due to “teenage angst.” Father reports hx of polysubstance abuse, food restriction with self-induced vomiting. Last alcoholic drink 5–6 hours before presentation. History of withdrawal symptoms but no hospitalizations for withdrawal seizures or DTs.
Cachectic with temporal wasting. Tachycardic (heart rate 106, BP 92/40). QTc prolonged at 480, moderately febrile (temp 39C). No respiratory distress with clear lung sounds (RR 26). Abdominal exam benign. Fine resting tremor present. Diaphoretic. Moving all extremities spontaneously. Hyper—almost intentionally exaggerated—patellofemoral reflexes. Examination revealed bruise on right lateral bicep.
Pt is a high-dynamics witching in a competitive training environment. Possible viral intoxication syndrome although symptoms likely multifactorial, including sequelae of moderate to severe malnutrition, polysubstance abuse with possible withdrawal syndrome. Differential diagnosis/rule out: systemic lupus erythematosus, acute infection, liver failure, severe hypokalemia, alcohol withdrawal syndrome.
Offered inpatient treatment for constellation of symptoms and physical exam findings suggesting multiple possible life-threatening conditions. However, patient appears to have decision-making capacity and he and his father, who is his legal power-of-attorney in any case, declined. I warned him about my concerns for life-threatening arrhythmia and withdrawal and strongly recommended close monitoring, preferably inpatient.
Recommend lab work today and close monitoring with repeat lab work in a few days: complete blood count, electrolyte panel, ANA with magic antibody reflex+SLE reflex, toxicology panel, liver enzymes.
Expressed concern to C. Lehrer regarding pt’s suitability for further Level 4 training.
Prescriptions:Iron replacement, potassium replacement, eszopiclone (for insomnia), sertraline (for depression)
Diagnoses:Primary:Fever (idiopathic);Secondary:Substance abuse disorder; unspecified eating disorder; major depressive disorder
CHAPTERTWENTY-ONE
NOAM
Come by the apartment for dinner.
The text was waiting on Noam’s phone when he got out of Swensson’s Friday strategy class, Noam instantly tilting the screen away from curious gazes as he opened the messaging app. Lehrer never texted him anything incriminating, but even so the last thing Noam needed was Ames or Bethany catching his name on Noam’s phone.
Not like they didn’t already know, of course, but ...
“I’m meeting a friend for dinner,” he told them when he split off from the group at the stairs. “I’ll see y’all later tonight?”
