Age: 1.5
Sex: M
Vaccine: DTAP, PNC, VARCEL
Symptoms: Anorexia, Pyrexia, Tremor, Vomiting
Clinical narrative: 03/11/03 08:00 am TC from parent c/o possible adverse reaction following 03/10/2003 immunizations done on child. States child reluctant to eat last pm and felt hot all night. Woke up this am throwing up and whole body shaking really hard. States she bathed him this am after he threw up and had shaking episode and he seemed fine in the tub. States she took him to her mothers house this morning so she could go to work and the grandmother asked if pt was running a temp following immunization yesterday. Parent stated she didn't think so, but reports she did not measure temp with thermometer. Parent reports she went to work and grandmother called her @ 07:00 am stating pt temp was 105.3 degrees F. Parent states grandmother then put cool washclothes on pt and administered PO Tylenol to help her reduce fever. Parent states that grandmother phoned her again with interventions and that the temp was 102.3 degrees F. Discussed possible reaction of elevated temp after child received immunizations and encouraged to follow up with child's PCP today. Discussed with parent that to call MD's office. Pt stated she would try to get pt in to see MD for follow up. Questions encouraged and answered. Compliance enforced. Parent also states that one arm redder than another @ vaccine site. unable to elaborate on details since she was at work and not with child at time of conversation. 03/11/2003 08:30am tc to pt. Message left on answering machine to have her contact signal. 03/11/2003 09:10am tc to pt. Message 2 left for her to contact . 03/11/2003 09:30am tc to parent states she phoned MD and is awaiting him to return her call to see if MD will be able to asses pt today. Parent states she will phone if able to get child into office today. 03/11/2003 08:00 LE Parent concerned that shaking episode was possible "febrile seizures" 03/11/2003 11:20am tc from grandmother, states pt temp now @ 102.4 degrees F, but he is more alert and active now than he was at 07:00am today. States she continues to administer PO Tylenol and rotates dosage Q 3 hours PO Motrin. Encouraged to offer frequent fluids and offer bath to child to aid in temperature reduction. Voiced understanding states she plans to offer popsicles if child will take. States she cant still tell that he doesn't feel well. States that pt did give Tylenol through the noc of 03/10/2003 and was unable to assess his temp because she did not have thermometer and has been able to assess pt's temp regularly today. Enc to notify of results and to follow up with assessment of child by his PCP as recommended. 03/12/2003 tc to parent. She states that she stook pt to see MD yesterday afternoon and the nurse believes pt had an allergic reaction to the DTaP shot given 03/10/2003. Pt reports that pt is not to receive DTaP booster @ age 4. Instead he is to receive DT. Discussed need for medical exemption in pt's records. Parent states she will notify clinic and request that they fax a medical exemption form on DTaP requesting that pt only receive DT. Parent states child does not have temp this am and feeling much better. States his arms continue with some redness. Enc to continue interventions with warm cloths to immunization sites. Voiced understanding.