Age: 0.01
Sex: M
Vaccine: HEP
Symptoms: Tonsillitis, Upper respiratory tract congestion, Upper respiratory tract infection, Visual acuity tests normal, Vomiting
Clinical narrative: Information has been received from the pediatric medical record from a physician's office concerning a 3 day old male infant with congenital umbilical hernia, respiratory distress and jaundice in the hospital at birth (reported in WAES # 0712USA09111) who on 16-APR-2008 was vaccinated with a dose of RECOMBIVAX HB (manufacturer unknown) in the hospital. On  23-APR-2008 the baby had the elective circumcision procedure without any complication. Baby's temperature was 99.1 On 30-APR-2008 the baby visited the doctor's office for his two weeks visit. He was fussy at night. He had positive red reflex test and the doctor wanted to see him in two weeks. His heart rate was 150, respiration was 40 and temperature was 98.3. On 07-MAY-2008 the baby was seen by the doctor in his office for follow up eye check up. The infant still had positive red reflex bilaterally. He was advised to be seen in two weeks. On 08-JUL-2008 the baby visited the doctor's office for check up. His pulse rate was 136, respiration was 24 and rectal temperature was 98.6. The baby was spitting up a lot. The doctor's assessment in this visited was that the baby had umbilical hernia early reducible and mild laryngomalacia. He reassured the mother that umbilical hernia and laryngomalacia will resolve over time. On that day the baby was vaccinated IM with a dose of PEDIARIX and PREVNAR. On 15-AUG-2008 the baby was brought to see the doctor. His temperature was 102 in the AM. In the office the temperature was 98.6 and pulse was 120. It was reported that the baby was irritable, lethargic on that day but was not given formula (just pedialyte). He had diarrhea previous night. His temperature was 102 and felt hot. He slept a lot on that day. He was irritable when woke up. He was given TYLENOL and he felt little better. The baby had watery stool x1 in the doctor's office. The doctor's assessment was fever, viral gastroenteritis, possible sepsis and questionable urinary tract infection (UTI). Currently he was afebrile and advised to push fluids. He was to be observed for one week and if crying increase or condition worsens then he was to be taken to the emergency room. On 18-AUG-2008 the baby was taken to the doctor's office for his visit. His rectal temperature was 98.1 rectal, heart rate was 124 and respiration was 20-22. The baby still had diarrhea (watery stools), anorexia and he was fussy, irritable, crying and woke up with crying. The doctor's assessment was diarrhea/vomiting likely viral. He had contact dermatitis of buttocks. A rapid stool test for rotavirus was done which came back as positive. Plan was to check for fecal culture and sensitivity (C& S), lipids. He was to switch to lactase formula x 48 hours. On 03-SEP-2008 the baby visited the doctor's office for immunization. His heart rate was 124 and rectal temperature was 98.1. He did not have any problem at this visit. He was taking formula well but did not have solid food yet. Reactive rotavirus was reported to be resolved. The baby was vaccinated IM with the second dose of PEDIARIX ACTHIB and PREVNAR. He had normal hearing and vision test. On 6-NOV-2008 the baby visited the doctor's office for his six month's check up. It was noted that he baby had dry skin at back. The baby was slightly congested recently. He was eating baby food and mashed potatoes. The doctor had the diagnosis of umbilical hernia, and dry skin on back on this visit. The baby was vaccinated IM with the third dose of PEDIARIX ACTHIB and PREVNAR. He was also vaccinated IM with a first dose of FLUZONE. On 12-NOV-2008 the baby was seen by the doctor in the office. He was brought in by his mom for a one day history of fever, cough and shortness of breath. As per the mom the baby became unwell yesterday morning and developed a temperature to 101 at home. It was noticed that he had hacking cough. He had hard time breathing when he was coughing. Mom reported that the baby had a hacking cough and it came in spasms. He was having hard time breathing. He was not drinking much. On physical examination the baby's axillary temperature was 100.2, rectal temp was 99.8. Pulse rate was 180 beats per minute. O2 saturation was 98% on room air and respiration rate was 60 to 70 per minute. On respiration examination he had some mild intercostal recession. Assessment for the baby was bronchiolitis with a positive respiratory syncytial virus (RSV). The baby was given albuterol nebulizer 0.625 via blow-by in the doctor's office. His respiratory rate came down to 40 with a pulse rate of 185. His breathing was less labored and he was able to sleep comfortably. He was observed for an hour in the office and appeared comfortable. At the time of discharge he was breathing better. He was also given TYLENOL 116 mg by mouth x 1 while in the office. The doctor reviewed with the mother the etiology of bronchiolitis and asked her to prop up the mattress in the baby' crib if he was breathless laying flat in the evening. The mom will use saline nose drops and a bulb syringe to keep his nose clear and continue the nebulizer every 4-6 hours as needed. She had to take the baby to the emergency room if breathing becomes worse and did not improve with nebulizer otherwise the baby will be seen in the office in the morning of 13-NOV-2008. On 13-NOV-2008 the baby was seen in the office for a follow up visit. It was reported that he was somewhat better. His rectal temperature was 99.9 and apical pulse was 152. Respiration rate was 60. The assessment for this visit was bronchitis. On 14-NOV-2008 he was seen in the office and his bronchitis was reported as resolving. His rectal temperature was 99.5 and heart rate was 141. On 02-JAN-2009 the baby visited the doctor's office. His temperature was 98.7 and pulse was 140. It was reported that the baby was ill for a week. The baby had minimal discharge of white exudates from nostrils. The assessment for this visit was tonsillitis, conjunctivitis and rhinorrhea. The baby was started with amoxicillin. On 29-JAN-2009 the baby was seen by the doctor in his office accompanied by mom. He was off amoxicillin for two days. He did have congestion and had greenish discharge from eyes. He was better with the amoxicillin but it came back again. Rectal temperature was 99.9, respiration was 48 and his heart rate was 140 on this visit. The doctor's note reported that it was difficult elicit red reflex and the baby had mild bilateral conjunctivitis. The physician's assessment was conjunctivitis, urinary tract infection and RAS secondary to upper respiratory infection and anemia. He was prescribed polymyxin eye drop, saline nose drops, and to observe. His total iron binding capacity level (TIBC) to be checked. His hemoglobin was 10.6 on that day. He will be getting antibiotics if he will continue to have fever. On 05-FEB-2009 the baby was vaccinated IM with the second dose of FLUZONE. On 10-FEB-2009 the baby visited the doctor's office. His rectal temperature was 99.2, pulse was 148 and respiration was 48. He had nose bleeding, congestion, fever (102.3) on 09-FEB-2009, and cough. The baby had right nostril bleeding. He had greenish nasal discharge and got more congested. The mother thought that the baby was teething. The assessment for this visit by the doctor was fever, coughs (bloody nasal discharge) and sinusitis. He was treated with AUGMENTIN 40 mg /kg q 24 hour TID x 1. He was to be checked in three days. On 13-FEB-2009 the baby went to the doctor's office for the follow up visit. He was on AUGMENTIN for 48 hours and was doing better. He had no cough, nasal discharge, fever and no nose bleeding. It was reported that baby was awaiting teeth. The assessment was sinusitis/fever. The doctor advised to call if further problems happen. His rectal temperature was 97.4, heart rate was 160 and respiration was 40. The outcome of the events was not reported. No other information is available. All medical records will be provided upon request.