Age: 1.18
Sex: M
Vaccine: FLU3, HEPA, MMR, VARCEL
Symptoms: Malnutrition, Mean cell haemoglobin decreased, Mean cell volume decreased, Middle ear effusion, Mononucleosis heterophile test negative
Clinical narrative: Medical History  Dec 21 to Present Allergies :  Amoxicillin & Omnicef Medications given (12/26-1/21) Additional Medications given during hospitalizations (not listed): Zithromax Liquid 100mg/5mL  x 5 days 12/26-12/31 (ED) Prelone Syrup 15mg/5mL  x3 days (12/26-12/28)  (ED) Omnicef 250 mg 15ml SUS 60ml (1/6-1/8)  Determined to be allergic-DNF (PEDs)  Xopenex .63/3ml NEB SOL every 4-6 hours x 3 weeks (12/26-1/21) (ED, PEDs, MC) Clarithromycin 5ml SUS 100ml 1/2t twice daily x ten days (1/11-1/21) (PEDs) Prednisone 15mg/5ml SOL 1 1/3 t x 5 days (1/11-1/16) (PEDs) Ibuprofen  Concentrated Infant drops for fever over 101 (12/21-1/21) (PEDs) Acetaminophen 1.0ml, 80mg for fever over 101 (12/21-1/21) (PEDs) Medical Tests given (12/26-1/21) Additional medications given during hospitalization (not listed): 12/26/10 Chest X-ray (ED)  Conclusion:  Pneumonia LT Lung, Resp Infection 1/9/11 RSV (PEDS)  Conclusion: Neg 1/9/11 Chest x-ray (MC)  Conclusion: No lg patches of pneumonia, Resp Infection 1/11/11 RSV (PEDS)  Conclusion: Neg 1/14/11 Chest X-ray (Nemours, OP) Conclusion: Clear 1/19/11 CBC (PEDS)  WBC  7.7 k/ul and RBC 4.13 m/ul 1/21/11 CBC (PEDS)  WBC  5.7 k/ul 1/21/11 Strep (PEDS) Conclusion: Neg 1/21/11 Flu (PEDS) Conclusion: Neg 1/22/11 (ED) CBC, Chest xray, Strep, Flu, Mono Conclusion: Neg  Diagnosis (12/26-1/21) Pneumonia, Febrile Illness, Respiratory Infection, Virus of unknown origin, Allergic Reaction to Omnicef, Chicken Pox, Double Ear Infection, Hives, Wheezing, sore throat, fluid in ears  Dec 21, 2010 (Tuesday) Patient was seen at Peds for 1 year physical.  Had a cough/cold that had persisted on and off for 6 weeks prior, which is why his 1 year immunizations were delayed. Otherwise healthy, wt is 22 lbs.  Dr checked cough and w/no fever immunizations were administered:  Hib, PCV7, MMRV & Flu.  Patient had a 101 fever three hours after receiving immunizations. Treated with infants Tylenol drops 1.0 ml.   Dec 22-25, 2010 (Weds-Sat)   Patient continued round the clock fever with diminished appetite and fluid intake.  Patient did not want to crawl, play or do anything but sit in a chair and be held.  Fever continued at 101-102 and was treated with Tylenol and Ibuprofen, every 6-8 hrs. Dec 26, 2010 (Sunday)  Patient stopped eating and drinking.  Pediatrician's office was called.  Fever continued at 102 and was treated with Tylenol and Ibuprofen.  Patient was taken to the Medical Center in the evening by parents and seen by Dr. for wheezing and listlessness.  Diagnosis at MC was: Pneumonia (left lung), Febrile illness, Respiratory infection.  Patient was prescribed Zithromax x 5days and Prelone x 3 days. Dec 27, 2010 (Monday)  Patient drank juice and banana for breakfast.  Seems much better with the Zithromax antibiotic and Prelone Steroid.  Treating fever with Tylenol and Ibuprofen. Dec 30, 2010 (Thursday)  Patient was seen at Peds for an ER Follow-up by Dr. Both ears are infected.  Chest is sounding better.    Dr. warns current antibiotic most likely will not clear ear infection. Jan 6, 2011  Patient was seen at Peds by Dr.  Has a fever of 101.5.  Ears are both infected.  Chest sounds clear.  Is prescribed Omnicef 250mg 15ml SUSP 60ml ½ t x 10 days. Jan 9, 2011 (Sunday)   AM:  Patient was seen at Peds for wheezing and breathing trouble.  Crackling was heard in his chest (LT lung) by Dr.  A breathing treatment with .63 Vyoxyin was administered in the office.  Patient has developed a rash of hundreds of red spots similar to measles rash or hives. RSV test is performed and is neg.  Diagnosed with a potential allergic reaction to Omnicef.  Dr. advised to take to another facility if breathing trouble is not better with breathing treatments of Vyoxyin every 4-6 hrs. PM: Patient was taken to the ER due to wheezing. Chest x-rays show no large patches of pneumonia.  Patient diagnosed with respiratory infection.  Advised to continue with breathing treatments every 4-6 hours. Jan 11, 2011 (Tuesday)  Patient was seen at Peds by Drs. and given a breathing treatment of Vyoxyin in the office, as there is wheezing and crackling in left lung.  Still has hives (100's of red spots), fever and cough.  Fever continues to be 101-102.  Treating with Tylenol.  Prescribed Clarithromycin 5ml SUS 100ml 1/2t twice daily x ten days (1/11-1/21) and Prednisolone 15mg/5ml SOL 1 1/3 t x 5 days (1/11-1/16). Jan 14, 2011 (Friday)   AM:  Patient was seen at Peds by Dr for a follow-up.  Chest sounds a little congested. PM:  Chest X-ray's performed.  Chest x-ray's were clear. Patient presents with a couple of blistery type red spots, different from the previous red measles type rash.  Dr diagnosis as mild case of chicken pox. Jan 18, 2011 (Tuesday)  Patient is cranky and has a fever of 102.5.  Gave him Tylenol at bedtime.  Seems like the Clarithromycin after 6 days is no longer effective and his progress has stopped.  Wants to be held and cries when put down.  Is lethargic all day. Jan 19, 2011 (Wednesday)  Patient was seen at Peds.  Has a fever of 102.5.  Disposition is pretty good today considering high fever.  WBC is 7.7 k/ul (normal).  RBC is  4.13 m/ul (low) with low HGB (10.3), HCT(31.2%), MCV(75.6) and MCH(24.9) (all low).  RDW is 19.6% (High).  Blister spots are noted to be Chicken Pox by Dr.  Eight spots are noted. Jan 20, 2011 (Thursday) Patient was listless and cranky all day. Did not want to be put down or play.  Is eating and drinking normally in AM. Fever ranged from 101 in AM to 104 before bedtime.  At 5:30PM when work up from nap, discovered he had vomited all over his bed and himself.  Was sweaty and clammy.  Fever was 103.  Gave Tylenol for fever at 6:45pm.  Has no appetite.  Refuses food, is drinking pedilite periodically 1/4 cup about every 2 hours. Jan 21, 2011 (Friday)  6:45am Patient's fever was 103. Gave him Ibuprofen for fever at 6:45am.  Patient was seen at Peds for excessive fever.  Fluid is behind his left ear.    Strep is Neg.  Flu is Neg.  WBC dropped  from two days ago to 5.7 k/ul.  12:30pm fever is 102, 1.875 ibuprofen given.  5:30pm Temp is 103.3 1.0ml acetaminophen, 30 mins later, patient throws up yellow liquid.  Large volume (3/4c  1 c).  6pm, Acetaminophen suppository, 80 mg given.  Refusing food and drink. Patient is lethargic all day. Jan 22, 2011 (Saturday)  AM: Check on patient in middle of night 12:30am temp 103.2, 1.0ml acetaminophen given.  6:30am temp 103, 1.875 ibuprofen given.  Patient sleeps till 11am with no food or fluids since 7pm yesterday.  I wake him up and give him ½ c pedialite. Temp is 98.4 after ibuprofen.  Extremities are very cold.  Eats a couple of cereal pieces, is extremely lethargic and will not play and cries when put down.      PM: Called PEDS and spoke to Nurse, after hearing symptoms, advise we take patient to another facility.  Took to facility at3pm.  Temp is 104.4 at triage.  Childrens ibuprofen given at triage 4.2 ml.  Three hours later temp is 99.4.  Patient is extremely lethargic and cries when put down.  Sometimes he is just laying in my arms staring off into space and then will sit up very fast cry and for a few seconds and then lay back down. Pain?  Patient is seen by Dr. (ED) after having chest xrays (clear), CBC (normal) and mono (neg), as well as urine check (normal).  His temp at 10:30pm is 102.6 and the ED gives him 4.2ml Childrens ibuprofen . Dr suggests patient may have Mono.   Dr talks with other Dr (PEDS) and arranges for us to follow up with him Sunday 10 am.  Dr recommends PEDS contact Dr. to see patient. Jan 23, 2011 (Sunday) Patient is not eating, but is drinking about ½ c pedilite every 2 hrs.  His temp at 8:00 am is 102.6, gave his 2.1ml infants ibuprofen. Patient was seen at PEDS by Dr.  Dr. suggests patient has a virus and he will refer us to another Dr. Patient's temp is 99.4, chest is clear, Slight fluid behind left ear.   5:00pm patient's temp is 103.2 and 2.1 ml ibuprofen  is given.  Patient is lethargic and listless all day, only wants to be held and is motionless/relaxed, drifting in and out of sleep.  Refuses to drink, has not drank since 3:30pm, put to bed at 9pm. Jan 24, 2011 (Monday) 1:45am, Patient is crying, Small, firm bowel movement.  Temp is 102.8 and  2.1mL ibuprofen is given.  Went to Dr (infectious Diseases) and she was alarmed at patient's lethargic state.  She admitted us to another Hospital.   Jan 24, 2011  Jan 28, 2011 (Monday  Friday) He is discharged with a diagnosis of Sinusitis and Chronic Otitis. February 4, 2011 Patient is taken for a follow-up with Dr. (infectious Disease).  Encephalitis is suspected.  Patient is not walking or crawling.  Dr. re admits patient to Hospital. February 4, 2011  February 16, 2011  It is found that he is not immune to many of the viruses that he has received vaccine for.  His IGG levels are low and both his T cells and B cells are low.  He is becoming malnourished and extremely lethargic.  He is not eating and placed on an NG tube.  Has frequent vomiting and diarrhea.     February 16, 2011  Present The doctors decide that patient's case is beyond their ability to treat him.  They refer him to another facility.  He is transferred via Ambulance with a referral to Dr. (Immunology).