Age: 12.0
Sex: F
Vaccine: HEP, VARCEL
Symptoms: Cough, Rhinitis, Wheezing
Clinical narrative: Information has been received from the mother of a 12 month old female patient who on 03/12/02 was vaccinated with a first date of Varivax. Concomitant vaccination the same day included a third dose (reported as a second by patient's mother) of Hepatitis B vaccine recombinant (yeast). On 03/12/02, "a couple hours after the vaccination" the patient began wheezing and coughing. The patient was seen by her physician but her symptoms did not subside, according to the patient's mother. The patient's mother took the patient's to the emergency room on the night of 03/13/02, 'because she was scared". The patient was treated with Albuterol and a liquid steroid (steroid unspecified). The mother of the patient stated that she felt it was the Varivax which caused the coughing and wheezing. Also, the patient's mother felt that Hepatitis B vaccine recombinant (yeast) was not associated with the wheezing and coughing since this was the patient's second dose and "the first time she was fine". FOLLOW UP information from a registered nurse indicated that the patient has had a past medical history of office visits for upper respiratory infections with runny nose and cough. On the day of vaccination the patient did have documented in her chart a cough and runny nose, but no fever. It was reported that the patient had no problems with vaccines in the past. On 03/13/02, the patient was seen in the office for cough, grunting and fatigue since last PM which was 03/12/02, the date of vaccination. The patient was treated with an albuterol treatment in the office and the physician's diagnosis was "Wheezing with possible infection". The patient was prescribed albuterol and chlorphreniramine tannate (+) phenylephrase tannate (+) pyrilamine tannate (Rynatan). As other 03/19/02, the office had not heard from the patient's mother and was not aware that the child had a visit to the emergency room. Additional information has been requested.  Follow up 08/23/2002: "Follow up information from a registered nurse indicated that the patient has had a past medical history of multiple office visits for upper respiratory infections with runny nose and cough.  On the day of vaccination, the patient did have documented in her chart a cough and runny nose, but no fever.  It was reported that the patient had no problems with vaccines in the past.  On 03/13/2002, the patient was seen in the office for cough, grunting and fatigue since last PM which was 03/12/2002, the date of the vaccination.  The patient was treated with an albuterol treatment in the office and the physician's diagnosis was "Wheezing with possible infection".  The patient was prescribed albuterol and chlorpheniramine tannate (+) phenylephrine tannate (+) pyrilmaine tannate (RYNATAN).  As of 03/19/2002, the office had not heard from the patient's mother and was not aware that the child had a visit to the emergency room.  Additional information from the physician's office was received which indicated that the patient was vaccinated with a first, second, and third dose of Haemophilus B conjugate vaccine (+) hepatitis B vaccine recombinant (yeast) on 05/10/2001 (Lot # 638838/1759K), right thigh 07/12/2001 (lot # 638136/1589K), left thigh and 03/12/2002 (lot # 640503/0933L) right thigh, respectively.  There was no illness at the time of vaccination and no adverse events following prior vaccination.  The reporter indicated that on 03/12/2002, at "12:30am", within 12 hours of the Haemophilus B conjugate vaccine (+) hepatitis B vaccine recombinant (yeast), the patient developed a rash and respiratory distress with grunting, malaise and reactive airway disease (RAD).  on 04/10/2002, the patient recovered.  The reporter considered the patient's rash, respiratory distress, grunting, malaise, and RAD an other medical event. (OMIC) EMERGENCY ROOM REPORT:  03/13/2002 @ 21:16.  Chief Complaint: Shortness of breath and wheeze.  History of Present Illness: This is a 1-year old female brought in by her mom with concerns of shortness of breath.  Patient seen by her physician earlier today for congestion and shortness of breath.  Mom stated she was given an albuterol nebulizer treatment in the office and sent home on an inhaler with a spacer and a cough medicine.  Mom states she thinks the cough medicine was Tanafed.  However, it made the child very irritable.  The patient febrile today, appetitie unchanged with no vomiting or diarrhea.  No history of reactive airway disease or wheezing in the past.  Positive family history of asthma.  Past Medical History: Normal spontaneous vaginal delievery.  Allergies: None, Physical Examination: vital signs: 101.7 F, pulse 146, respirations 32, pulse 97% on room air.  Weight 10.6kg.  General: Patient alert, active, and crying but consolable being held by mom.  color pink.  Head, eyes, ears, nose and throat: Extracular movements intact.  Tympanic membranes mobile, noninjected.  Nose patent.  Mouth and thrat moist, noninjected.  Neck: supple.   Normal range of motion; Lungs: bilateral expiratory wheeze.  External retraction.  Negative rales.  Heart: Regular rate and rhythm, no murmur.  Abdomen: Positive bowel sounds, soft, nontender, nondistended.  Extremitites: within normal limits.  Skin: no rash.  Neurologic: Grossly intact.  Chest x-ray was donw and revealed negative infiltrates.  Urgent course of treatment: Albuterol given via nebulizer treatment and patient tolerated well.  Good seration bilaterally with negative wheeze..  Orapred 15mg also given per mouth.  Assesement: 1) Reactive airway disease 2) viral illness.  Plan: 1) Crapred syrup 3/4 teaspoon daily x 4 days.  Start tomorrow 2) Continue albuterol 3) Follow with PMD in two days if not better.  03/13/2002 Exam: RAD/CHEST PA/LAT Clinical indication: Fever, SOB, Reason for exam? Fever, crackles, retractions.  Nature of injury/illness: fever.  Abd lung sounds.  Findings: PA and lateral view of the chest where obtained for review.  The present exam is compared to the exam of 08/17/2001.  The lung fields appear clear.  No focal infiltrates or plueral effusion is seen.  The heart size is within normal limits.  The bony structures are unremarkable.  Prominent thymic tissue remains.  Impression: No focal infiltrate of pleural effusion is seen. EMERGENCY ROOM REPORT 03/14/20002 @ 2206:  Chief complaint: Wheezing and vomiting.  History of Present Illness: The patient is a 1-year old girl whose mother reports that Tuesday she was given a chickenpox and hepatitis vaccines at 2:30 by her pediatrician.  At that time she had slight cough and was prescribed Tnafed.  At 5:00pm Tuesday evening she developed wheezing and shortness of breath.  Wednesday she was taken back to the doctor, who did a nebulizer in the office and prescribed an inhaler with a spacer, as well as another decongestant.  The patient had persistent symptoms, and came her last night at which time she was given another nebulizer, and was prescribed grapred after being given a dose.  The mother reports she has not been able to get the child to keep down Orapred today, but has been given Albuterol every six hours or so.  She has vomited three times today and has not been eating.  She has no previous history of wheezing.  Immunizations: Up to date.  Physical Examination: General: Well-appearing 1 year old active and playful.  Vital Signs: Weight 10.4kg, 98.1F, pulse 180, respirations 28, pulse ox 96%. Head, Eyes, Ears, Nose and Throat: Anterior fontanelle is open and flat.  Pupils equal, round reactive to light.  Sclerae normal, tympanic membranes are normal.  Pharynx slightly injected without exudate.  Lungs: The patient has slight expiratory wheezing without retractions.  Cardiac: Regular rate and rhythm.  Abdomen: soft, non-tender.  Skin: Good turgor, no rashes.  Neurologic: Within normal limits.  Urgent Care Course: the patient is given Orapred 7 mi per mouth.  She is given Albuterol 2.5mg nebulizers.  Subsequent reevaluation she had improvement, and almost complete resolution of expiratory wheezing.  Air exchange was excellent.  No retractions were present.  Discharge Diagnoses: 1) Upper respiratory infection 2) Reative airway disease.  Discharge Instructions:  I recommend that the mom increase the Albuterol to 2 puffs every 4 hours for 1-2 days, then every 6 hours and as needed for wheezing.  I have recommended that the patient be rechecked in one to two days.  If she is not much better to continue Orepred as prescribed.  Encourage fluids.  Conditions on Discharge: patient was discharged in good condition.  05/31/2002 Exams: RAD/CHEST PA/LAT Clinical Indication: Persistent cough/Pneumonia.  REason for exam? Persistent cough/pneumonia.  Nature of injury/illness: persistent cough/pneumonia.  PA and lateral Chest History: Persistent cough.  PA and Lateral View of the chest were obtained for review.  The exam is compared to 03/13/2002.  Some areas of increased density are seen int he medial right lung base with parial loss of the hemidiaphragmatic border.  This was not seen on the previous exam.  The left lung field is clear.  No pieural effusion or pneumothorax is seen.  The heart size is within normal limits.  Impression: Subtle area of increased density is seen in the medial right lung base with partial loss of right hemidiaphragmatic border.  This may represent early infiltrate and recommend clinical correlation and followup imaging.  06/18/2002 Exams:  RAD/CHEST PA/LAT Clinical Indication: F/U for infiltrate pneumonia.  Reason for exam? F/U for infiltrate pneumoia, wheezing.  comment: has the infiltrate resolved or getting worse? Nature of injury/illness: F/U for infiltrate pneumonia, wheeze.  Chest: AP and Lateral images are compared to 05/31/2002.  The patients previously demonstrated right middle lobe pneumonia has completely cleared, there is no residual infiltrate or evidence of pleural abnormality.  Additional information is not expected.