Sex: M
Vaccine: HEP
Symptoms: Rash vesicular, Respiratory distress, Respiratory rate, Respiratory syncytial virus bronchiolitis, Respiratory syncytial virus test positive
Clinical narrative: Information has been received from a physician concerning a 27 day old male with a history of premature, respiratory distress, bruising of face, jaundice, subdural haemorrhage neonatal and poor sucking reflex (WAES #0807USA00388) who was vaccinated with a first dose of RECOMBIVAX HB at birth, on 15-JAN-2009. On 10-FEB-2009 the baby was seen by the doctor for circumcision. Parents had no concerns except that he had some white stuff on his tongue. He ate, voided, and stool okay. Physical examination showed the baby had extensive oral thrush involving the entire oral mucosa and the tongue looked quite inflamed. The doctor's impression was healthy 3 week old with extensive oral thrush. The doctor did circumcision using a 1.2 Plastibell. There was no significant blood loss. Hemostasis maintained at the end. Nystatin oral solution 2 ml swish around the mouth 4 times a day for 7 days was prescribed for his oral thrush. On 10-MAR-2009 the baby was taken to a clinic with cough and congestion and wheezing presented with respiratory distress. It was reported that he had a history of severe respiratory difficulty and he had not been eating for the past 5 days, mom worried. He was coughing a lot. When he ate, sometimes he would cough so much that he would gag and then throw up. He had no fever, he had no diarrhea, no skin lesions. He had not been exposed to anybody with respiratory symptoms. Mom stated that dad smoked, but he did not smoke in the house. Mom did not smoke. Baby did not go to day care. There was no family history of recurrent respiratory problems, except an uncle had asthma. Mom had mild allergies. Physical examination showed the baby was in acute respiratory distress. He had subcostal and intercostal retractions, there was no nasal flaring, there were suprasternal retractions. There was rhinorrhea. Oropharynx was pink and moist. His temperature was 98.5, respiratory rate was 38 to 42. Pulse oximetry in the clinic was 94, after treatment it dropped but then went on and dropped below the 90s. At the time of examination, it was at 84, 200% with blow by oxygen support. He had a lot of crackles, inspiratory and expiratory rhonchi. Air movement was very tight. Respiratory syncytial virus (RSV) and influenza tests were obtained and RSV was positive, influenza A and B antibody were negative. His potassium was 6.3 but it was heel stick. CO2 content was 26.0 mmol/L. Chest x-ray showed atelectasis or pneumonia at the right hilar region. It was reported that the baby was retracting so much and he had hypoxic episodes. Nebulized albuterol was given to the patient without improvement. He continued to wheeze seriously. So the baby was admitted to the hospital on the same day. Admission diagnoses were acute respiratory distress, hypoxia, RSV bronchiolitis and pneumonia. On admission because of his temperature spikes, the doctor started him on amoxicillin. He received nebulized albuterol, first continuous then every 6 hours, then it was increased to every 2 hours and since 12-MAR-2009, he had been on every 4 hours, then it was increased to every 2 hours and since 12-MAR-2009, he had been on every 4 hours and doing very well. He did have 2 episodes of temperature going up to 101 but it had not been that thigh since the past 48 hours. His lowest pulse oximetry was 84, which made the doctor start him on blow-by. Since 12-MAR-2009 he had been between 91% and 100% on room air. He required oxygen for 2 nights but since "last night" (12-MAR-2009), he had not needed oxygen. He was eating. He was voiding. He stooled. He still had a lot of retractions but air movement was improving. Mother reported that she felt that he was a little more active. He had no vomiting during the admission. During admission, his temperature was 96.8 to 99, pulse rate was 121 to 60, respiratory rate was 36 to 84 when agitated. On 13-MAR-2009 the patient was discharged from the hospital with instruction to mother on proper feeding and doing his nebulized albuterol 3 times a day and in between as necessary. Discharge physical examination showed he still had subcostal and intercostal retractions but they were a lot less than before. Amoxicillin would continue at 200 mg twice a day to complete 10 days. The baby was to be followed up in 1 week. Discharge diagnoses were acute respiratory distress, hypoxia, RSV bronchiolitis and pneumonia. On 20-MAR-2009 the patient had a follow up visit. It was reported that the mother had only had to use nebulizaer one time over the last 3 to 4 days. So he had been doing much better. He had minimal cough without fever. Physical examination showed his head looked like he was in a breach position. It was broader across the forehead and then narrowed posteriorly which usually would not be for concern, but from the anterior fontanelle back, there was a ridge along the sagittal suture. Head circumference though, head is growing fine. The impressions were well child, resolving RSV and possible craniosynostosis. He was given his 2 months immunizations and would follow up at 4 months. On 15-MAY-2009 the patient was taken to the clinic for well child visit. Parents had no concerns other than his head shape. Physical examination showed there was a persistent ridge from anterior fontanelle back on the sagittal suture. He still hasdnarrowing of the occiput. He had broadening of his forehead. The impression was well child with possible craniosynostosis. A head computed tomography (CT) was performed on 19-MAY-2009 which revealed long and narrow skull, likely the result of sagittal synostosis and external hydrocephalus. On 11-JUN-2009 the patient presented to the doctor because he had bumps on his head. Mom said that she noticed 1 bump initially, and now there were many others. It did not seem to bother him. He had no history of fever. He ate well. He voided and stooled okay. He had a runny nose. Physical examination showed he did have vesiculopapular lesions, not erythematous, on the occipital area of his scalp. He had no sign of secondary infection. He did have significant plagiocephaly. His anterior fontanelle was open, flat, soft. The impressions were benign vesicular lesions, probably molluscum contagiosum. The doctor thought the molluscum was very unusual to see in this age group, however, it was still benign. The doctor would just observe it. If overtime there was any sign of secondary infection, they would deal with it, but he expected this to involute by themselves. The patient also was diagnosed with upper respiratory infection. Saline nose drops and BENADRYL as needed were prescribed. On 15-JUL-2009 the patient had a well child visit. He was doing well. Mother had no areas of concern. Physical examination did not find abnormality. He was given his 6 months immunizations. On 27-JUL-2009 the patient was brought to the doctor by his mother because of cold. He had had cold for some days at that time. He had no fever, but he had been very cranky. He was seen some time ago according to mom and there was a mention that he had some fluid in his ear. He had not been sleeping very well. He had bumps on his head. Mom said that initially he had just 1 but now the left ear was draining some purulent fluid with perforatic TM. Right ear looked normal. Oropharynx was normal. He did have multiple lesions on his scalp around the occiput. There were 2 that had formed abscess. The others ones are just pustules. They are quite tender. The doctor incised 6 of these lesions and all of them drained lots of pus and I took swabs for culture. Wound culture showed moderate growth in 18 hours of coagulase-negative Staphylococcus. Usually presented as normal skin flora. The patient was diagnosed with acute suppurative left otitis media, upper respiratory infection, multiple scalp small abscesses. The doctor was starting him on KEFLEX 125 mg 3 times a day for 10 days and advised mom on warm compresses and dressing this wound once every day using clindamycin gel. The patient was to be followed up in 1 week for reevaluation. Additional information is not expected. All medical records will be provided upon request.