Age: 4.0
Sex: F
Vaccine: DTAPHEPBIP, FLUX, MMR, PPV
Symptoms: Asthma, Obesity
Clinical narrative: This spontaneous report was received from a physician, via a medical records and refers to a 4 year old female patient. The patient was brought in for the well-child visit and the following portions of the patient's history were reviewed and updated as appropriate: allergies, current medications, past family history, past medical history, past social history, past surgical history and problem list. The patient was on a balanced diet, was toilet trained and she had no constipation and no behaviour concerns. She was not snoring, had a dental home and had no risk factors for anemia, tuberculosis or lead toxicity. The patient had no immunizations up-to-date. On 18-MAR-2016, the patient was vaccinated subcutaneously in the right lower forearm with a 0.5 ml dose of M-M-R II (lot number and expiration date were not reported). On the same day, the patient was vaccinated with pneumococcal 13v conj vaccine (crm197) (0.5 ml dose, intramuscularly in the left deltoid), influenza virus vaccine (unspecified) (0.5 ml dose, intramuscularly in the right deltoid) and PEDIARIX (0.5 ml dose, intramuscularly, in the right deltoid). Concomitant therapies were not reported. On 18-MAR-2016, the patient was diagnosed with mild persistent asthma without complication. There were no concerns about the patient's hearing. The patient's field vitals tests performed on 18-MAR-2016 at 15:25 included: blood pressure 121/74 (unit not provided), pulse 139 (unit not provided), body temperature 36.7 Celsius degrees (98 Fahrenheit degrees, via oral screening), respiratory rate 20 (unit not provided). The patient was in 98 percentile (Z=1.98) based on CDC 2-20 years stature-for-age data, in 100 percentile (Z=2.84) based on CDC years weight-for-age data and in 100 percentile (Z=2.70) based on CDC 2-20 years body mass index (BMI)-for-age data using vitals from 18-MAR-2016. The patient's growth parameters were noted and were not appropriate for age. The general examination showed that patient was alert, appeared stated age, was cooperative and moderately obese. Her gait and skin were normal. The patient's nose was enlarged with pale pink turbinates. Oral cavity examination showed that lips, mucosa, tongue, teeth and gums were normal. Eyes were with white sclerae, pupils were equal and reactive and red reflex was normal bilaterally. Ears were normal bilaterally. Neck was with no adenopathy, no carotid bruit, no jugular venous distention (JVD), supple, symmetrical, trachea midline and thyroid were not enlarged, symmetric, no tenderness, mass or nodules. Lungs were clear to auscultation bilaterally. Heart examination showed regular rate and rhythm, S1, S2 normal, no murmur, click, rub or gallop. Abdomen was soft and non-tender. Bowel sounds were normal and there were no masses or organomegaly. Genitourinary examination (GU) was normal. Extremities were normal, atraumatic, no cyanosis or edema. Neurological examination was normal without focal findings, mental status, speech normal, alert and oriented x3, pupils equal and reactive to light and accommodation (PERLA) and reflexes were normal and symmetric. The patent was assessed as a healthy child. The orders from the visit were: PEDIARIX intramuscularly, pneumococcal conj vaccine (unspecified), M-M-R II and varicella virus vaccine live (unspecified) subcutaneously, influenza virus vaccine (unspecified) greater than or equal to 3yo preservative free intramuscularly. The patient received prescription for FLOVENT HFA and PROAIR HFA as treatment for the event of asthma. To keep asthma diary, the patient was supposed to return in one month for follow up. It was also stated that on 10-JUN-2016, the patient was vaccinated subcutaneously in the right upper arm with a 0.5 ml dose of M-M-R II (lot number and expiration date were not reported). The outcome of the events was not reported. The relatedness between the events and M-M-R II was not reported. All available medical records will be provided upon request. Additional information has been requested.