Age: 0.33
Sex: M
Vaccine: DTAPIPVHIB, PNC13, RV5
Symptoms: Injection site warmth, Irritability, Local reaction, Screaming
Clinical narrative: Mom says his left leg is bright red and swollen from his hip to his ankle. There are bumps around the injection site and it is warm to touch. He is also screaming/crying/fussy. Mom is calling in today stating that patient was seen this morning and received 2 shots. May 25, 2017. 3:03 PM. Mom states that he is having a bad reaction to one of them. His leg is bright red and warm to touch. Patient won't stop screaming. Please advise. May 25, 2017. 3:04 PM. Phone call from mom transferred to me - mom says that patient was here in the office earlier and got vaccines. Mom states that they got home around 10:30AM and she gave him TYLENOL at 11AM. Mom says that he started screaming again. Mom says that he then went to sleep for another hour but once again woke up screaming again. I could hear him screaming in the background while I talked to mom. Mom says that she looked at his legs and the left leg is bright red from his hip to his ankle and is swollen and warm to touch. At the injection site there are tiny little bumps. He dose not have a fever. He did have a wet diaper earlier. After looking it appears that he got the PENTACEL in his left leg, this was his 2nd PENTACEL (according to the shot record scanned in he also received one on 3/22/17 with a previous PCP). I spoke with Dr. regarding this - he would like mom to take him to the ER now. Mom agrees and will go now. I did also instruct her to take photos of his leg and if she can so that she can show them to Dr. at his next visit here. I also asked mom to call later today with an update. Mom agrees. May 25, 2017. 6:18 PM. Mom says that the ER said it was a local reaction to the vaccine. They did mark it and said that if it is getting worse he needs to be taken back to the ER. Mom says that by the time they got to the ER his leg looked much better. She was told that it just a localized reaction to the vaccine. Mom says that she didn't even get to take pictures of it because by the time she got him to the ER there was nothing to take a picture of. She says that they advised her to continue giving TYLENOL every 4 hours and to watch closely. Mom agrees and will do this. She mentioned to me that she used to get allergy shots as a child and she used to react to them. Her reaction was not to the shot itself though, she says that it was due to the needle they used. They started ordering her a different/special type of needle and the reactions stopped. She doesn't have any further information on this. I advised mom that I will be reporting this to the VAERS system - I wanted to inform her of this because sometime they may contact the parent for an update or questions. Mom is fine with this. I will wait until we receive the ER report before I submit the VAERS report as this should be included in the submission along with the immunization record and shot lot #/exp date. May 25, 2017. 6:34 PM. Update - Dr. sent the message back to the RN as I was updating. May 26, 2017. 1:11 PM. VAERS completed. This is a 4-month-17-day-old male who presents here with mom and dad states he had vaccines this morning. He got his polio vaccine in his left leg and they state the leg became red and the child cried every time they touched the leg. The redness has since gone away. He is still somewhat fussy. They got concerned and brought him over for evaluation.