Age: 13.0
Sex: M
Vaccine: HEPA, IPV, MMRV, HEPA, IPV, MMRV
Symptoms: Epistaxis, Hallucination, Headache, Lethargy, Loss of personal independence in daily activities
Clinical narrative: Document Contains Addenda           Chief Complaint  Recently received imms, reports a headache that developed thursday. Stayed home from school friday, complained of chest pains, bloody nose. Reports dizziness, stomach pains, only had fever on Friday night. Appetite has been low. Did go to school yeasterda  History of Present Illness    Mom brings in her 13-year-old son with concern of possible immunization reaction.  She brings in a very detailed list of the events for the past 5 days.  On 03/25/19, he received hepatitis A #1, IPV #4, ProQuad to satisfy MMR #2 and Varicella #2.  He did well for 3 days following this, then on 3/28/19, developed a severe headache, fever about 100-101, felt sweaty, very tired.  Continued with headache into the next day, still very tired with intermittent fever around 101.  Mom states "hallucinating "during times of fever, patient states he was hearing music or a choir, "seeing things "described as vivid dream would seem but knew he wasn't dreaming.  Mom denies seizure activity.  He developed his comfort in the mid chest, worse with eating, Tums did help this.  He has had a decreased appetite, denies vomiting.  On 03/30/19 states the fever subsided, chest discomfort subsided, more pain in the epigastric region.  Still felt tired and dizzy.  He is able to take fluids.  Mildly dizzy with standing.  Headache gradually subsided, on 3/31, did have 2 nosebleeds during the day, not severe.  The following day he had nosebleed twice again.  No other bruising, bleeding or petechiae.  He did attend school on 04/01/19, felt somewhat better still rather fatigued and mentally foggy.  He did go to school today, eating better, still notes some epigastric discomfort.  He has not had any previous immunization reactions.  They did not present to ER or UC.  He has been otherwise healthy, does very well in school.  Denies shortness of breath with exertion, no palpitations.  No redness or swelling at the vaccine sites.  Review of Systems    No fever in the last few days, headache has subsided.  No nosebleeds today.  Denies ear pain, sore throat, sinus tenderness or drainage.  No diplopia or vision loss, no light sensitivity.  No seizure activity, shaking, tongue biting.  Did have what he describes as hallucinations during fever, none since.  No exertional chest pain, has some upper abdominal discomfort with eating. No palpitations.  No presyncope.  Chest discomfort with eating he was having has subsided. no diarrhea, blood in stool.  No dysuria or frequency, no hematuria.  No swollen joints, rash.  No hx of anxiety disorder  Physical Exam Vitals & Measurements (Last Charted) T: 97.6  °F   HR: 82  RR: 16  BP: 140/80  SpO2: 98%  HT: 162.56 cm  WT: 54.5 kg  BMI: 20.6       Gen.: Pleasant 13-year-old male in no acute distress, accompanied by his mother.  He is alert and oriented ×3, conversant, vital signs reviewed. HEENT: Facies are normal, speech is fluent.  Pupils are equal round and reactive, extraocular movements are intact.  TMs are clear bilaterally, posterior pharynx is clear.  No sinus tenderness, no neck nodes or masses. CHEST: Chest is clear to auscultation bilaterally, no wheezes, rales or rhonchi. HEART: Heart is regular rate and rhythm, no murmur, gallop or ectopic beat.  No chest pain reproduced with chest wall palpation. ABDOMEN: Abdomen is flat, soft.  Normal bowel sounds ×4.  He does have mild to moderate epigastric tenderness with palpation.  No organomegaly or masses, no splenic enlargement.  The remainder of the abdomen is normal. EXTREMITIES: No swollen joints, no swelling in the extremities.  Gait is normal, no focal weakness.   No redness, swelling or pain over the vaccine sites. NEUROLOGIC: As above, extraocular movements are intact, no facial weakness.  No weakness of the extremities.  Exam nonfocal.  No nuchal rigidity.    Assessment/Plan     1. Fatigue   Headache, fatigue, fever, malaise are constellation of symptoms suggestive of viral etiology.  Timing not appearing consistent with vaccine reaction however cannot rule this out.  CBC, CMP pending.  Will submit VAERS report.  I was able to discuss his case with Dr. She did not feel this represented a vaccine reaction, most likely represented a concomitant viral illness, versus inflammatory type reaction to other components of the vaccines.  Symptoms are improving. Bland diet, supplements to decrease inflammation such as turmeric, Vit D and C may be helpful.  Advised observation for the next week, if no improvement or worsening symptoms, they will be able to see him in their clinic in follow-up.   2. Nosebleed   None today, will check CBC.   3. Viral syndrome   as above.   4. Vaccine reaction  Unclear whether this represent a true vaccine reaction, symptoms unusual.  VAERS report will be submitted.  Proquad licensed from 12 months through 12 years of age, still counts as valid vaccines per CDC/shot line.  Discussed with pediatrician, vaccines not thought be cause of his recent symptoms.  As per #1.   5. Epigastric pain   Will treat symptomatically with Pepcid AC OTC 2 times a day.  Bland diet as above, avoid spicy or greasy food.  Recheck if no improvement.    Problem List/Past Medical History  Ongoing Atopic dermatitis    Procedure/Surgical History Closed left wrist fracture.  Medications No active medications  Allergies  No Known Medication Allergies  Social History   Alcohol - Denies Alcohol Use   Employment/School   Student, Work/School description: 7th Grade.  Tobacco Smoking Status: Never smoked  Family History  Diabetes......: Mother and Grandfather Maternal.  Healthy adult: Father.  Protein S deficiency: Mother.  Immunizations  Lab Results  Diagnostic Results  Other Results      Addendum by PA on April 15, 2019 19:07:26 MDT (Verified)     Correct DOS is 4/2/19.