Age: 3.0
Sex: M
Vaccine: VARCEL
Symptoms: Hyponatraemia, Laboratory test abnormal, Pyrexia, Tachycardia, Tremor
Clinical narrative: Information including medical records has been received from a health professional concerning a 42 month old white male patient with no known drug allergies, no concurrent conditions, a history of recent otitis media treated with amoxicillin and according to the patient's mother, a history of a seizure two years ago for which medical attention was not sought (the mother did not remember if the patient had a fever at the time of the seizure), who on 10/16/03 at 14:30 was vaccinated SC in the left arm with a first dose of varicella virus vaccine live (lot # 646236/0544N). There was no illness at the time of vaccination. It was noted that the patient's pediatric immunizations were up to date. Concomitant therapy included amoxicillin. On 10/17/03 at 08:30, the patient had a witnessed seizure lasting approximately 2 to 3 minutes. The father stated the patient was shaking in both upper and lower extremities. After the seizure, the father noticed the patient was warm and placed him in a cool shower. Fever was noted. According to EMS, the patient was postictal at the scene. It was noted that prior to this, the patient had been completely well and he did not have a fever, cough, chest pain, shortness of breath, or abdominal pain and his appetite was good. The patient was taken to the emergency room accompanied by EMS. At the emergency room triage, the patient was alert and talking to his father. Medical records indicated grand mal seizure activity and a diagnosis of febrile seizure. The patient vomited one time in the emergency room. Physical examination revealed the following: temperature 102.3; blood pressure 130/56; heart rate 144; respirations 20; well developed; well nourished; alert; no acute distress; behavior completely normal; head normocephalic, non-traumatic; pupils equal, round and react to light; ENT and mouth mucous membranes moist; oropharynx clear; left tympanic membrane pink, right normal; throat clear; neck supple, full range of motion, no adenopathy; chest non-tender; respirations clear to auscultation; heart regular rate and rhythm, no murmur; abdomen soft and non-tender; skin warm, dry and pink, no contusions, ecchymosis, rashes or other lesions. On 10/17/03, the patient had the following test results: urinalysis showed glucose at 250 mg/dL and trace protein; electrolytes showed sodium 134 mmol/L and CO2 16 mmol/L; chemistry showed calcium 9.4 mg/dL, glucose 188 mg/dL and 180 mg/dL, BUN 15 mg/dL, creatinine 0.5 mg/dL and alkaline phosphatase 265 U/L; metals showed magnesium 1.6 mg/dL; blood cultures showed no growth after 6 days; CT brain scan was normal; chest x-rays showed a subtle patchy infiltrate in the right upper lobe that was noted by the physician to be unremarkable. At 08:50, the patient was treated with 9cc of oral acetaminophen. At 10:30, the patient had a temperature of 100.8 degrees. At 11:30, the patient had a temperature of 100.2 degrees. At 12:22, the patient was treated with 1gm of IM ceftriaxone sodium. At 12:50, an exit assessment revealed a stable patient with a temperature of 99 degrees, a heart rate of 130 and a respiratory rate of 20. The patient remained alert, active, appropriate and non-toxic appearing. The patient was discussed twice with the attending physician who had recommended IM ceftriaxone sodium and requested a fasting glucose be done the following morning. On 10/17/03 at 13:00, the patient was discharged to home in stable condition. The reporter noted that the patient had recovered. Additional information is not expected. (OMIC)