Age: 1.11
Sex: M
Vaccine: DTAP, HEP, HIBV, IPV, MMR, VARCEL
Symptoms: Agitation, Asthenia, Convulsion, Cough, Diarrhoea
Clinical narrative: Information has been received from medical records through a consumer concerning an otherwise healthy 13 month old male who lived with his parents and had no smoke exposure with an allergy to something purple or orange (patient's mother could not remember) (also reported as no known drug allergies; also reported as ibuprofen) and a history of neonatal jaundice, elevated bilirubin, periorbital edema, and neonatal dry, scaly skin who was vaccinated with a dose of MMR. Suspect vaccinations included a dose of varicella virus vaccine live, an IM 0.5 mcg dose in the left thigh of hepatitis B virus vaccine, and a dose of HIB conjugate vaccine. Other concomitant vaccinations included a dose of diphtheria toxoid (+) pertussis vaccine (+) tetanus toxoid and poliovirus vaccine inactivated. On 11/29/03 at 12:35 PM, the patient was brought to the emergency room by his mother with the complaints of fever, cough, and lethargy since the previous night. Vital signs were noted to be temperature 40.2, pulse 178, respirations 24, and pulse oximetry was 98% on room air. Immunizations were reported to be up to date. Airway and breathing were normal, circulation was warm and dry. Sensory/motor was within normal limits. The patient had received acetaminophen the night prior. A portable chest x-ray was obtained. A CT of the head was obtained for febrile seizure with right arm weakness. Lab tests including a CBC, Chem 12, catheterized urinalysis, and blood culture x1 were obtained. An IV was established and a 120 cc bolus of normal saline at 46cc/hour was given. Identified nursing problems included infection potential. The diagnosis was febrile seizure. The patient was noted to be well developed and well nourished. A review of the eyes revealed normal lids and conjunctiva. A review of the cardiovascular system revealed some tachycardia, no murmurs, or gallops and no S3/S4. A respiratory exam revealed lungs that were clear to auscultation, symmetric, and breath sounds equal bilaterally. A skin exam revealed warm and dry skin with some sweating. Other assessment showed that the patient was acutely seizing and was maintained in a lateral recumbent position. The airway was patent. No cyanosis was noted. The seizure lasted about two minutes. The clinical impression was a febrile seizure. A consult was placed. The emergency room nursing notes indicated at 12:50 PM that the patient had diarrhea once last night, runny nose, and small cough. Baby is crying, easily comforted by mother. Denies any nausea/vomiting. A review of systems at 1:15 PM revealed a cough, congestion, flu symptoms, and a fever. The onset of these symptoms was noted to be the day prior. Severity was classified as moderate. At 1:25 PM, the nursing notes indicated that mom brought baby out in arms, baby was seizing. Physician was notified. At 1:25 PM, the patient was given acetaminophen. At 1:35 PM, peds cath done. Unable to get urine sample. Will recath after fluids have had time to go in. At 1:35 PM, 1000 cc NS was started via a pump in the left hand. At 2:20 PM, peds cath done for urinalysis. Sent to lab. At 4:10 PM, patient sleeping. IV has no redness or swelling at site. At 4:20 PM, report called to unit. Patient up to floor. The patient's pain was assessed as 0/10. A physician history and physical revealed that the patient was brought to the emergency room by his mother with a of a fever. While in the emergency room, he had a witnessed two minute generalized tonic-clonic seizure. His oxygen saturations were fine during the seizure. He was noted to be breathing comfortably through the whole thing. After the seizure, the emergency department doctor noticed some weakness of his right arm. He was given acetaminophen in the emergency room, lab work was drawn, and a chest x-ray was obtained. The mother indicated that the patient's fever started last night and that he just kind of felt warm all through the night and again that morning. She did not have a thermometer at home to check. He has had a little bit of a runny nose and a cough. He had been drinking well and eating some today. No vomiting or diarrhea was noted. The patient's family history was not significant for febrile seizures in a close relative, although a distant cousin had a daughter that had a febrile seizure. There was no history of other seizure disorders. Of note, the father was ill with a fever and feeling generally ill at the moment. A review of systems revealed a temperature of 40.2, pulse 178, respiration 24, and pulse oximetry 98% on room air. He was alert, active and fussy during exam. Head was atraumatic. Eyes, conjunctiva, and sclera were clear. Ears were symmetric. Tympanic membranes were clear. Nares were patent. Mouth and mucous membranes were moist and pharynx was clear. Neck was supple with no rigidity or lymphadenopathy. Heart had a regular rate and rhythm without murmur. Lungs were clear to auscultation. Abdomen was soft, non-tender, and non-distended. Capillary refill was about two seconds. The extremities were warm and well perfused. The face was symmetic and gag reflex was intact. When he cried his case was symmetric as well. He was moving his neck with equal strength. It was a little hard to do a motor evaluation of his upper extremities because he had an IV in his left hand. He did independently move his right some but the mother did not think it was quite back to his normal yet. His tone was good. He was moving his lower extremities fine. Deep tendon reflexes were 2+ throughout. A non-contrasted CT scan of his head was negative. The report indicated that the ventricles were of normal size, shape, and position. There was no shift of the midline. There were no significant intracranial abnormalities identified. The visualized portions of the orbits and paranasal sinuses were unremarkable. The assessment was febrile seizure with a history of right arm weakness. The plan stated that it had now been a good hour and a half since his last febrile seizure and he was moving his arm, reaching for food, and the mother felt it was back to normal at that point in time. Given the fact that he spiked such a high fever and there was this kind of reportedly focal exam after the seizure, he would be observed overnight in the hospital. He had a peripheral IV in place and received a 120 cc bolus of normal saline. He was kept on D5 1/2 normal with 20 of potassium chloride at 46 cc/hour which was maintenance for him. He was allowed to eat a regular diet. His chest x-ray was negative. The report indicated that the chest revealed a bit of motion artifact and no evidence of pneumonia or other specific findings. He was monitored with a pulse oximetry. He was monitored closely overnight and if he had another febrile seizure during the course of the night, at that time a lumbar puncture would be done. Given the fact that his neurological status was back to baseline and he was feeling much more comfortable and given the family history of viral illness in the household, it was felt that this was the most likely cause of his fever. The patient had a febrile seizure probably secondary to viral illness but blood and urine cultures were pending as well as a urinalysis. The patient was scheduled on acetaminophen through the night Q4H. An overnight admission was anticipated. Doctor's orders from 11/29/03 at 3:00 PM indicated that the patient was admitted for observation with a diagnosis of febrile seizure with right arm weakness secondary to viral syndrome. Routine vital signs were ordered. Pulse oximetry was to be continued. An IV of D5 1/5 NS with 20 mEq of KCL at 44 cc/hour was to be maintained. Diet was regular. Activity as tolerated. The physician was to be called with seizure activity or any other concerns. Medications included acetaminphen. On 11/29/03 at11:20 PM, the acetaminophen order was changed to rectal suppositories Q4H. The IV was to be left out. On 11/30/03 at 11:00 AM, progress notes indicated that the patient did well overnight. Still spiked fever. No seizure. Moving arm well. Doing well this AM. Spiked fever last night ranging 99-100 on acetaminophen. Heart rate 140-162, respiratory rate 24-30, oxygen saturation 95-97%. Intake 917. Output 750. Alert, active. Tympanic membranes clear, abdomen soft, lungs clear to auscultation, extremities warm, well perfused, heart regular rate and rhythm. Moving all extremities equally. The assessment was a 13 month old febrile seizure secondary to viral syndrome. The plan was to discharge to home, schedule acetaminophen suppositories at home, and follow up with the physician the next day. Doctor's orders from 11/30/04 at 11:16 AM indicated that the patient was to be discharged home with a diagnosis of febrile seizure, viral syndrome. Diet was regular with activity as tolerated. Medications included acetaminophen. The patient was to follow up with the physician the next day. On 12/4/03, the blood culture final report indicated no growth after five days. See lab section for all other lab results. This is an amended report. The narrative now reads that other vaccines included hep B virus vaccine rHBsAg (yeast) IM 0.5 mcg dose in the left thigh (manufacturer UNK) instead of the hep B included as a suspect therapy.This is an amended report. The date received by the manufacturer for the case now reads 16Jun04 instead of 15Apr04.  No further information is available.