Age: 0.17
Sex: M
Vaccine: DTAPHEPBIP, HIBV, PNC, RV5
Symptoms: Gastrooesophageal reflux disease, Haemoglobin normal, Increased upper airway secretion, Irritability, Laboratory test normal
Clinical narrative: Information has been received from a physician concerning a 2 month old male with gastrooesophageal reflux disease and a history of (constipation, blocked tear duct, decreased feeding, seborrhea, baby acne WAES #0802USA04905)who on 30-SEP-2008 was vaccinated with ROTATEQ. Concomitant suspect therapy included PEDVAXHIB. Other concomitant therapy included PREVNAR, PEDIARIX, and ZANTAC. On 05-NOV-2008 the patient's mother called the clinic to report that while at appointment on 04-NOV-2008, the employee "scolded" the mother for letting the baby sleep from 7 pm to 7 am and they charted his weight as 11 lbs 9 ozs as below 10%, and according to the chart he would be at the 25%ile. On 12-NOV-2008 the patient was seen in the clinic. He was taking nutramigen 4 ozs every 4 hours, except at nights when he was sleeping. The physician questioned whether he had cow's milk allergy. The assessment was normal exam. The diagnosis was failure to thrive (FTT) but patient appeared healthy, mild infantile seborrhea and mild GERD. Diagnostic laboratory tests were obtained to included complete blood count (CBC) with differential and other diagnostic labs. Plan was to increase feeds to 6 ozs every 4 hours. His ZANTAC was discontinued. Return to office on 04-DEC-08 for well child care and review of labs. On 13-NOV-2008 all the laboratory results were normal. Hemoglobin was 11.2, CMP was normal with protein 6.1, albumin 4.2. On approximately 18-NOV-2008 the patient was brought to clinic with cough and nasal congestion x 6 days at times "difficult breathing", "rattling sounding chest", afebrile. Treatment was use of vaporizer and saline drops aspirator. Physical findings showed no acute distress, alert and active. Tympanic membranes (TM's) had + erythema, he had bilateral nasal congestion. Diagnosis was bilateral otitis media and upper respiratory infection (URI). He had good weight gain (weight not reported). Prescription for amoxicillin 250/5, 3/4 tsp two times daily (BID) x 10 days was given. On 04-DEC-2008 at 4 month old, the patient was seen in clinic for well child care. His weight was 12.1 lbs. Review of system showed that the patient was recovering from the otitis media (also reported as left otitis media) He experienced some diarrhea with diaper area reddened. Nystatin cream was prescribed to be use TID. Immunizations were administered as noted above. The physician noted a healthy 4 month old male, to return to office in 2 months. On approximately 11-DEC-2008 the baby was in clinic for cough, slight runny nose x 2 days, afebrile, waking up at nights and diarrhea x2. He finished the amoxicillin on 10-DEC-2008. The diagnosis was mild URI, received bilateral otitis media (BOM) and the patient was to call if symptoms worsen with no improvement. To return to office as needed. The parent was informed to increase head of bed, use vaporizer. On 05-FEB-2009, 6 months old, the baby was seen in clinic for well child care and received immunizations as noted above. Weight was 13.5 lbs. On 19-FEB-2009 the patient came to clinic. The complaint was that he was awakening during the night "crying uncontrollably x 2 days, he was afebrile. Physical findings showed that he was alert and in no acute distress. TM's were normal, pharynx normal. Diagnosis was fussy infant probably due to teething. He was to return to office if no improvement in 24 hours. On 02-MAR-2009 the patient came to clinic with nasal congestion, cough and wheezing x 3 days. He was afebrile and drinking well. Saline drops were being used. Physical findings showed no distress, normal respiratory rate, afebrile, widespread rhonchi and few wheezes. Diagnosis was mild bronchiolitis. On 03-MAR-2009 the patient was seen and chart review showed bronchiolitis, which worsened during the night with "choking on phlegm", afebrile. Treatment was aspirator, cool mist vaporizer, saline drops. Physical findings showed respiratory rate of 48, and bilateral wheezes. He was given a trial with albuterol nebulizer which gave dramatic clearing. Medical history showed that the baby's father, mother and sister and grandmother had asthma. Prescription and instructions were given and review of when to use nebulizer. The baby was seen on 05-MAR-2009, he had good aeration bilaterally, nasal congestion, scant rhonchi and rales. He was placed on PULMICORT nebulizer 0.5 daily, and to continue albuterol every 4-6 hours as needed, normal saline and vaporizer. On 26-MAR-2009 the patient visited the clinic due to vomiting x 2 days, fever 100.9 in the morning and slight congestion. He was drinking well and voiding. Diagnosis was bilateral otitis media, vomiting and diarrhea. He was put on amoxicillin 250 mg BID for 10 days, to have head of bed increased, increased fluid and use of vaporizer. Parent was to call if worsened, otherwise to return to office in 2 weeks. On 06-APR-2009 the patient was seen in clinic for cough and runny nose x 4 days and continuation of diarrhea. Parent gave MOTRIN, not given amoxicillin. Physical findings showed diarrhea, increased respiratory rate without retractions, mild wheezing and rhonchi. He was given PULMICORT and albuterol nebulizers and to follow up. On 20-APR-2009, the baby was seen and chart was reviewed. He had a slight rash on his chin x 4 days. His symptoms from when he was seen on 06-APR-2009 for mild wheezing had resolved. Physical findings showed a slight irritative rash, his chest had cleared. The physician discussed bronchiolitis with the parent. Skin care management and education given. On 25-APR-2009 the patient was seen. He had fever up to 103.5 last night. He was given TYLENOL, MOTRIN. Physical findings showed temperature 101.4, wheezing bilaterally, respiratory rate of 44. Diagnosis which was discussed was right otitis media. He was put on amoxicillin 250 BID x10 days. On 07-MAY-2009, 9 months old, the patient was seen by the physician. His TM's had bilateral erythema. The physician discussed otitis media with the parent. Diagnosis was bilateral otitis media. He was given ZMAX 100 SQ x1 and was to take 50 mg daily x 4 days. Additional information is not expected. All medical records will be available upon request.