Age: 0.2
Sex: M
Vaccine: DTAPHEPBIP, HEP, HIBV, PNC, RV5
Symptoms: Ultrasound abdomen normal, Upper respiratory tract congestion, Vital capacity, Vomiting, Weight increased
Clinical narrative: Information has been received from a physician, other health professional and pediatric medical records concerning a 9 week old male with oral thrush and bilateral scrotal hydrocele a history of premature birth, neonatal respiratory distress syndrome, jaundice neonatal and inguinal hernia repair (September 2007) who on 20-SEP-2007, 20-NOV-2007 and 07-FEB-2008, was vaccinated PO with a 0.05 ml dose of ROTATEQ, respectively. Concomitant therapy included PEDIARIX, PREVNAR and Hib conj vaccine (manufacturer unknown). On 25-SEP-2007, the patient was seen by the physician for having forceful emesis for 3 to 4 days. The infant was drinking 5 oz at a time and his mom had cut back to 3 oz for the past 3 to 4 feedings. Since the onset, he has had forceful emesis about every 3rd feeding. No other symptoms noted at this time. It was reported that at least 2 family members have a history of pyloric stenosis. An abdominal ultrasound was performed and no evidence of pyloric stenosis was reported. The infant's vital signs for this visit were reported as heart rate 142 b/min, respirations 40 r/min, temperature 99.3 F, rectal and weight 9.56 lb. The physician's plan was to follow up in 2 months for his immunizations at 4 months of age. On 03-OCT-2007, the patient experienced congestion for the past 2 days and had been associated with subjective fever. His mother had tried TYLENOL at home. He was noted to have increased work of breathing and had been fussy since 02-OCT-2007 but feeding 3 to 4 ounces every 3 hours. His vital signs were reported as heart rate 142 b/min, temperature 99.9 F, rectal, height 22.25 inches, weight 10.25 lb, body mass 14.6 kg/m2, head circumference 37.5 cm and his oxygen saturation was 98%. On 05-Oct-2007, a CT scan of the head was performed for fever and concern for intracerebral hemorrhage which resulted in, findings suggestive of sinus disease and right mastoiditis. No acute intracranial findings were noted. It was also reported in October 2007, the patient experienced viral meningitis. No further information was available regarding the viral meningitis. On 20-NOV-2007, the infant fell off the bed in the morning. He landed partially on a pillow on the floor. He cried but did not lose consciousness. There was no real swelling where he hit his head. His vital signs for this visit were reported as heart rate 145 b/min, respirations 42 r/min, temperature 99.4 F, rectal, height 24.75 inches, weight 13.38 lb, body mass index 15.4 kg/m2 and his head circumference measured 40.5 cm. Physician's assessment was physical well baby. On 07-FEB-2008, it was reported that the infant had a rash all over his body for "about a week." The mother used NEOSPORIN and stated the rash felt hard and dry on his arms and wrist. She also noted that emesis sporadically came out of his nose. His vital signs for this visit were reported as Temperature 99.5 F, rectal, height 26.5 inches, weight 15.94 lb, body mass index 16 kg/m2 and head circumference 42 cm. The physicians assessment of the skin was reported as dry splotchy erythematous rash extensor surfaces of arms, some on trunk with scratching noted, several sharply demarcated circular areas. The patient was diagnosed with eczema. The physician ordered ranitidine HCl 15 mg/ml, take 1 ml 3 times daily for acid reflux (diagnosis date unspecified) and triamcinolone acetonide 0.1% Cream, apply sparingly to affected area 3 times a day for one week then once or twice a week to control symptoms. On 07-MAR-2008, the patient was seen by the physician for follow up of eczema and reflux. It was reported that the rash was worse and had been present on the soles of his feet since shortly after his last visit, "last month". The mother was reportedly making changes in detergent, soaps, etc. without improvement. She had also been moisturizing his skin. The onset of the rash may have coincided with introduction of solids other than cereals. The physician's assessment of the infant's skin was reported as dry splotchy erythematous rash extensor surfaces of arms, some on trunk with scratching noted and several dermacated circular areas. His vital signs for that day were heart rate 118 b/min, respirations 30 r/min, temperature 99.5 F, rectal, height 26.5 inches, weight 18.00 lb, body mass index 18 kg/m2 and head circumference 42.0 cm. The physician's orders to treat the eczema were BENADRYL 12.5 mg/5 ml syrup. Take one teaspoon daily every 6 hours as needed fro itching, PREDNISONE 15 mg/5 ml, take one teaspoon daily for 3 days, 3/4 teaspoon daily for 3 days, 1/2 teaspoon daily for 3 days, 1/4 teaspoon daily until gone and a dermatology referral. The physician's plan was to treat symptomatically with antihistamines/steroids pending Dermatology consult. At the time of this report, the patient's outcome was unknown. Additional information has been requested. All available medical records will be provided upon request.