Sex: F
Vaccine: HEP
Symptoms: Constipation, Developmental delay, Gastrooesophageal reflux disease, Musculoskeletal stiffness, Posture abnormal
Clinical narrative: Information has been received from a physician via medical records concerning a 4 week old female who on 30-JUN-2006 was vaccinated with a first dose of RECOMBIVAX HB (manufacturer unspecified). At six months of age it was noted that the patient had a developmental delay. In records from the neurology clinic dated 18-JAN-2007 it was noted that the patient was "very stiff" when sitting up and had difficulty turning her head to the right. The patient was no rolling over and did  not like lying on her belly (she cried as if in pain). The patient had "shaking extremities" when she woke up and she slept with stiff arms/fists clenched. It was noted that her mom had rheumatoid arthritis. The patient was referred for PT/OT. On 23-JAN-2007 the patient had a physical therapy evaluation. She was referred for the evaluation for delayed gross motor milestones and torticollis. In the records from this visit it was indicated that the patient's pediatrician was concerned about possible cerebral palsy due to the stiffness in her legs and tilted position of her head. In these medical records it was noted that the patient had a history of reflux and possible abdominal pain (per her parents report). The physical therapist indicated that this could account for some of the patient's head posturing (torticollis) as well as low back and lower extremity stiffness. It was noted that the patient had decreased flexibility of her right upper trapezius muscle which could be secondary to her preferred head position. The patient was noted to be awake, alert and interactive during the evaluation with age appropriate attention. The physical therapist indicated that the patient's level of sensory responsiveness was appropriate. Muscle tone was noted to be within normal limits and excessive resistance to quick passive stretch in any muscle groups of the lower extremities. The patient's range of motion was normal limits with the exception of cervical rotation. Rotation to the left: full active and passive; to right full passive, to 75 deg active. Passive flexion with rotation to her right full range, to her left moderately limited. The patient's strength was decreased antigravity strength. The diagnoses made were torticollis and gross motor developmental delay (motor problem with limbs). Outpatient physical therapy was recommended for the patient. In a neurology clinic note from 10-MAY-2007 it was noted that the patient was rolling over, crawling, pulled to stand, cruising, occasionally feeding herself and babbling. The patient "graduated" from weekly PT on 08-MAY-2007 and continued to us the helmet 23 hours/day. At the patient's 1 year well child checkup on 01-AUG-2007 it was noted that the patient's developmental tasks were normal however the diagnosis of developmental delay remained. At the patient's 15 month well child checkup on 07-NOV-2007 it was noted that the patient's developmental tasks were all normal. It was also specified that the patient "had no reported developmental problems". Additional adverse experiences noted in these medical records included constipation (27-AUG-2006), reflux, and a urinary tract infection (15-AUG-2007). The patient also had adverse experiences after vaccination with MMR II (WAES # 0712USA07978) and VARIVAX (Oka/Merck) (WAES # 0712USA05193).