Age: 0.19
Sex: F
Vaccine: DTAP, HBHEPB, PNC, RV5
Symptoms: Body temperature increased, Bronchial hyperreactivity, Choking, Congenital naevus, Cough
Clinical narrative: Information has been received from a physician concerning an 8 week old black female with respiratory syncytial virus infection/bronchiolitis and mongolian spots (WAES# 0809USA02399) who on 05-DEC-2007 was vaccinated with hepatitis B virus vaccine rHBsAg (yeast) (+) Hib conj vaccine (OMPC). Concomitant therapy included diphtheria toxoid (+) pertussis acellular vaccine (unspecified) (+) tetanus toxoid, poliovirus vaccine inactivated (unspecified), (PREVNAR) vaccine (CRM197) and (ROTATEQ) vaccine live (human-bovine). On 12-DEC-2007 the patient experienced a rash on her arms, legs and face. She was seen in the emergency department. The patient was told to use "RUCCXINE". The infant's mother called the office for a follow up appointment and she stated it seemed to be better. On 05-FEB-2008, the patient developed an upper respiratory tract infection (URI) with a runny nose, thick clear nasal discharge and she was wheezy. Her temperature was reported was reported as 99.4. She was scheduled to receive her immunizations but the physician deferred them until the following week. On 13-FEB-2008 the patient experienced acute otitis media in the right ear and congestion. Her temperature was reported as 98.8. She did not have a fever. She did not have a fever, she had rhinorrhea, cough, good appetite and she was not sleeping well. Her maximum temperature was 101 F which was 2 days ago (11-FEB-2008). At the time of the examination, the infant was alert. The left tympanic membrane was neutral with serous effusion and the right tympanic membrane was full inferiorly, dull, red, opaque effusion. Her chest was clear to auscultation. The infant was prescribed amoxicillin. The mother was instructed to follow up in 3 weeks. It was noted that the infant was ok to get her 4 month shots on this day. On 05-MAR-2008, the patient returned to the office for a follow up visit regarding the infant's ears and fever. Her temperature was reported as 99.3 and the mother reported a possible hemorrhoid. On examination the physician noticed a questionable area that may have been a hemorrhoid. It was reported that the infant strains when she poops but it is always soft. Her lungs were clear to auscultation. The physician reported that the infant was recovered and prescribed 0.5 tsp of witch hazel to the hemorrhoid every other day. On 24-MAR-2008, the patient experienced congestion, cough, runny nose and watery eyes. The mother reported that the cough was not as bad as when the infant had RSV. She also reported that last week the infant had a lot of coughing and was choking on her phlegm. She was drinking normally but did not have any solid foods on this day. The infant was alert, had watery eyes and was fussy at times. She also had thick clear discharge from her nose. The physician prescribed dye free Benadryl, 2 cc and Tylenol PM. On 22-APR-2008, the patient was seen in the office for her 6 3/4 month check up. There were no current concerns and the infant was assessed as a well child. She received diphtheria toxoid (+) pertussis acellular vaccine (unspecified) (+) tetanus toxoid, poliovirus vaccine inactivated (unspecified), (PREVNAR) vaccine (CRM197) and ROTATEQ (human-bovine). On 30-JUN-2008, the patient was seen in the office. The mother reported that the infant was sleepy and had a bad cough. She brought her to the emergency room department because she was choking and having trouble breathing. Nebulizers were not done in the ED. She was instructed to use Tylenol which she used occasionally. The infant was eating normally, drinking Pedialyte and fruit juice. On examination at the office, the infant was still congested and fussy at times. She also had thick white mucous coming from her nose. Her respiratory rate was 25 and rhonchi was heard in her lungs. Her pulse ox was 98%. A nebulizer was given and she dramatically improved, faint rhochi was heard. The infant was diagnosed with viral bronchiolitis / RAD. The physician prescribed nebulizers every 4 to 6 hours and to follow up if the infant became worse or had a fever. On 09-JUL-2008, the mother returned to the office for a follow-up visit. She was unsure if she should continue using the nebulizer. She was using it 2-3 times a day, unable to go to once a day. She still hears a cough/rumble. Her eyes were reported as clear and the physician reported that the infant was recovering and to discontinue the nebulizers. He also prescribed Proventil MDI with a spacer, 2 puffs everyday. On 22-JUL-2008, the infant was seen for her 9.5 month visit. It was reported that the infant loved the Proventil and she does not have a cough. The infant received "TD". The physician noted her Monogolian spots on her back and shoulders. The assessment was a well child. The plan was to call if coughing and to follow up for her 1 year visit. This is one to two reports from the same source. Additional information has been requested.