Age: 0.14
Sex: F
Vaccine: DTAPHEPBIP, HIBV, PNC, RV5
Symptoms: Upper respiratory tract infection, Wheezing
Clinical narrative: This is in follow-up to report(s) previously on 10/13/2008. Information has been received from a medical records and a nurse practitioner concerning a 50 day old female baby with mongolian spots on back and a family history of asthma (mother) who on 26-FEB-2008 was vaccinated with a first dose of ROTATEQ (lot # not reported). On 29-APR-2008 and 09-JUL-2008, the patient was vaccinated with the second and third doses of ROTATEQ (lot #'s not reported). Concomitant therapy included doses one to three (26-FEB-2008, 29-APR-2008, and 09-JUL-2008, respectively) of (PREVNAR); diphtheria toxoid (+) hepatitis B virus vaccine rHBsAg (yeast) (+) pertussis acellular 3-component vaccine (OMPC) (manufacturer unknown). On 26-FEB-2008 the baby had a well child care follow up with the nurse practitioner and had complaint of spitting up. The baby's weight was 11 lbs 13 ozs, height of 23 inches and head circumference of 14 3/4 inches. The baby's formula was changed and the nurse practitioner's assessment was well infant. TYLENOL infant drops 0.4 mL was to be given every 4 hrs PRN. On 29-APR-2008 the baby had another well child care visit and was a well infant but for a beefy erythematous rash to diaper area assessed as diaper candidiasis. Nystatin cream BID 30g was prescribed. On 19-MAY-2008 the baby was seen by a physician and a licensed practical nurse, and had c/o difficult breathing with oxygen saturation of 97% on room air. Weight was 16 lbs 1 oz. The baby's eye was draining. She had stuffy nose, cough and congestion. The baby's mother said the baby was "wheezing" before upper respiratory infection (URI) started, and that eye drainage persisted since birth. Assessment showed scant purulent left eye discharge and dried nasal discharge. Oral mucosa was moist. Baby had expiratory wheezing bilaterally. Assessment was bronchiolitis and blocked tear duct. ALBUTERAL nebulizer was given x1 and baby improved and had no wheeze. Prescription for ALBUTEROL HFA was given to be given as 2 puffs via spacer every 6 hours x2 days then every 4-6 hours PRN. The parent was to continue massaging tear ducts and to follow up if symptoms did not improve. On 25-JUN-2008 the baby was seen at the health center. The nurse's assessment included weight 17 lbs 15 ozs. Oxygen saturation was 94-95% on room air. The baby had wheezing, cough x 2-3 days, stuffy nose, diarrhea and slight decrease in oral intake. The father had a bad cold. The baby was given a dose of ALBUTEROL HFA earlier today. The health care providers' exam showed dried yellowish discharge on lower eye lid, dried nasal discharge, and expiratory wheeze with mild intercostal retractions. Assessment was bronchiolitis. ALBUTEROL #1 was given and baby had improved AE with no wheezing or retractions. Prescriptions for: normal saline nose gtts (NSDND) #30ml and ALBUTERAL HFA 2 puffs via spacer every 4-6 hors PRN (use every 6  hours x 2 days then every 4-6 hours PRN was given. The baby was to have increased fluids and to be propped up sleeping. Instructions were also given to follow up if no improvement in 2 days or PRN. On 09-JUL-2008 the baby was seen by the nurse practitioner for well child care. Weight was 18 lbs 5 ozs, height 27 inches, and head circumference was 16 3/4 inches. The baby had no recent wheeze and chest was clear. Assessment was well child. Additional information has been requested.