Age: 3.0
Sex: M
Vaccine: HEP, MMR
Symptoms: Upper respiratory tract infection, Vomiting
Clinical narrative: Information has been received from a consumer concerning her son with no known allergies and no past medical history who was vaccinated with MMRII (lot 0109E). It was reported that the child also got "more than one hepatitis b vaccine shot". His mother did not know the specific dates of the vaccinations, but she did report lot numbers. The 1st lot number she reported was for hepatitis b vaccine recombinant (yeast) (MSD) (lot #615998/0642D) and the 2nd lot number she reported was for hepatitis b vaccine recombinant (yeast) (lot #2149A2-invalid lot). No other concomitant medications were noted. It was noted that in July or August 2000, the pt was dx'd with autism. Upon internal review, autism was considered an "Other Medical Event". Additional information has been requested. Follow-up info has been received from a physician's office. The child was seen on 02/10/2000 for evaluation of speech therapy. He weighed 36 pounds, had a temperature of 9702 and was on no medications. He did not talk much. He had been in therapy for 5 months and it was noted that the pt spoke 15-20 isngle words with no sentance and no disarticulations. He remained about 1 1/2 months behind, but he did say some words he didn't use to say. He had no repitive words and no echolalia, though he was able to communciate his needs. It was noted,"borderline (mild) MR." The child was being referred for a second opinion because of parents were not satisfied with his current therapy. The institution suggested mild autism and the family did not agree. On 04/30/2000 he was seen for his 3 year visit. All physical findings were normal. He weighed 37 pounds, was 38.5 tall, BP 90/48 and had a temp of 96.1. The only concern was his speech therapy. It was noted that he had no autistic features, was going to speech therapy and was to start occupational therapy. Plan was for a lead test, and an evaluation of his speech by another physician. It was noted that on 05/04/2002 the pt may have been diagnosed with autism. In September 2000 the pt was seen for ear pain that started the morning of his visit. It was noted that he wasn't sleeping well and woke up screaming and pulling his ears. He weighed 39.5 pounds, had a temp of 98.0 and was taking ibuprofen. It was noted that he had possible "BOM" but his typanic membranes could not be seen due to a large amount of ear wax. It was also noted that it was a difficult exam due to mild autism. He was prescribed ampicillin for 10 days, mineral oil 3 drops each ear for 10 days and continue ibuprofen for pain. On 10/10/2000 the pt was seen to re-check his ears. He weighed 38.5 pounds and had a temperature of 97.2. He had finished the amoxicillin and was using the mineral oil every day. The child contined to pick at his ear, was congested and had a runny nose. On exam he had cerumen impacted that was removable with a curette. An appointment was made with another physician for evaluation of his ears. On 11/01/2000 the pt was seen with complaints of vomiting twice that started that day. He weighed 37 pounds, had a temp of 96.5 and was on no medication. It was noted that he had no diarrhea, had a decreased appetitie and was taking some fluids. The impression was acute gastroenteritis. The plan was to do a rapid stress test and a throat culture if negative. He was to avoid mild and juice and take Dimetapp. He was scheduled for cerumen removal under sedation the following week. On 12/21/2000 the pt wsa seen for complaints of diarrhea that had been going on for 2 weeks. He weighed 39 pounds had a temp of 96.1 and was on no medication. It was noted that there was no vomiting and no blood in the stool. He was afebrile and had a rash on his bottom. Plan was to get a stoolC4S, a stoll C47, increase fiber and cut out milk and juice. On 12/22/2000 the pt's mother called and were told that both stool cultures had negative results. On 01/04/2001 the pt was seen for complaints of a runny nose, vomiting and pulling both ears. His ears had been bothering him for a week and the vomiting started that morning. It was also noted that he had diarrhea for 3 days, but his stool was normal that day. It was noted that he had a URI and gastroenteritis without dehydration. He was given cabinoxamine maleate hydrocodone bitartrate pseudosphedrine hydrochloride 6 hrs prn for runny nose. On 01/17/2001 the pt wsa seen for follow-up after hospitalization on 01/13/2001 for dehydration. He was discharged on 01/16/2001. He weighed 41.5 pounds, had a temp of 96.5 and was on no medication. He had no vomitin, but stil had loose stools. No blood was noted. He was afebrile and was sleeping good and eating good. On 01/23/2001 the pt was seen for pre-up to dental surgery for caries. He weighed 38 pounds, had a temp of 97 and was on no medication. He had no vomiting or diarrhea at the time and he was given the OK for his surgery that was to be done on 01/16/2001. It was noted that the time that the pt had a history of Pervasive Developmental disorder. On 02/21/2001 the pt was seen for complaints of a fever, headache and stomach pain that started the previous night. He weighed 40 pounds, had a temp of 97.5 and was taking Tylenol and Motrin. It was noted that the pt vomited once on 02/26/2001 and complaiend that his stomach hurt. HIs t-max was 100.5, his nose was stuffy, his throat was red and the impression was pharyngitis. It was nted AS+ and IPRS +. He was given amoxicillin for 10 days and another dental surgery was rescheduled. On 03/06/2001 the pt was seen for a clear for dental surgery. The pt weighed 41 punds had a temp of 98 and was on no medication. It was noted that ENT had diagnosed him with strep on 02/31/2001. He was given an OK for dental surgery. On 05/07/2001 the pt was seen with complaints of stomach pain that had been ongoing for 6 months. He weighed 41.5 pounds, had a temp of 94.7 and was on no medication at that time. It was noted that his bowel movements went from soft to diarrhea to constipation. Sometimes they were hard and sometimes they were watery. There was no blood noted. It was also reported that he gags when eating and is restless at night. The school nurse noted an increase in urine output. A UA was to be doen. The impression was constipation and bowel impaction. On 05/10/2001 it was reported that he used the suppositary and senna as ordered for two days and that morning had a moderate amount of watery stool with mucous. The Senna was discontinued and the child was to restart the rest of the protocol as ordered. On 05/14/2001 the pt's mother called requesting a peptide level for "autism change." Referral was given. On 06/28/2001 the pt was seen to check his ears and his urine. He weighed 40 pounds, had a temp of 98.4 and was on no medication. He was acting like his ears hurt and like it hurt to void. A small amount of stool was palpated on exam and his throat showed erythema. Impression was pharyngitis and constipation. A UA was done and he was given hisacodyl for 3 days, NOM , PO Bid for 2 weeks and suggestion of no bubble baths and increase in fiber. It was noted htat Tylenol and Motrin could be given prn. It was also noted that a rapid strep test would be done and throat culture if negative. On 09/12/2001 the pt was seen for a cold in the eyes that had been going on 2 weeks. The pt weighed 42 pounds, had a temp of 97.1 and was taking Dimetapp. It was noted tha this eyes were matted together, he had a runny nose (green), a hacky cough and congestion. There was no sore throat and no vomiting. His teacher reported one loose stool the day prior. On exam he had purulent discharge fro a stuffy nose, yellow discharge from the corners of his eyes. The impression was conjunctivitis and a URI. He was given gentamicin ointment ot be applied TID, amoxicillin for 10 days and "Palgic DS" prn. On 10/16/2001 the pt's mother called to report he was bitten by "fire ants." She was instructed to give Benadryl. He was then seen in the office. He weighed 44 pounds had a temp of 96.5 and was using diphenhydramine hydrochloride cream. It was noted that the pt had bites on his legs, back and scrotum. The "bite" on his scrotum ws athe worse and it had swelling and had "turned black." He was scheduled for color doppler ultrasound of the tests and surgery was consulted to rule out testicular corsion. He had decreased activity, was irritable and had decreased voiding, but would walk. On 10/21/2001 it was reported that the testicles were just bruised from swelling at the bug bites, but that it looked better. Upon internal review autism was considered an other important medical event. Additional info has been requested.