Age: 13.0
Sex: M
Vaccine: HEP
Symptoms: Convulsion, Fall, Tremor
Clinical narrative: 1/28/03 12:15pm phone call to health room aide to follow up on report of possible seizure experienced by pt. She reports that yesterday 1/27/03 at around 1:20pm while sitting in class, the teacher observed him drop his pencil and when he appeared to retrieve it, she noticed slight shaking with minimal tremors and a few seconds later he "took to the floor like a ton of bricks" to quote the teacher. At this part of the report from, she reported that pt later told him mom he was stretching his arms. Then reported that what the teacher observed was that he did not attempt to break his fall. He fell on his face, sustained a bruise to forehead, scraped tip of nose and a bruised area to right wrist. The teacher went to him and called his name and he came to. The first thing he later remembered was his teacher calling his name. A fellow student walked him to the nurse's office and the aide reported to me that he was a bit dazed but alert. She called RN who was at another site and she told her to observe him. She reports he was in the sitting position, he was coherent, gave appropriate responses to questions asked and he drank a can. She reported she was with him for the rest of the day and personally accompanied him to the bus. She reported that his mother took him to the ER, where the doctor said he was dehydrated and per mother's report, gave him IV's and was sent home some time yesterday evening. He is back at school today, has a brace to his right wrist for a sprain, and appears to be OK. 1/28/03 1pm TC placed to mother left message to call me on her answering machine. 1/29/03 8:10am TC mother to talk with her about pt. She reports he is doing well; that prior to his passing out at school, he'd been experiencing flu type symptoms of body aches, but no fever or nausea. Pt reported to her he stood up in class, stretched and sat back down, at which point he passed out. She reports ER doctor seemed to think he was dehydrated and his BP bottomed out when he sat back down, and he passed out. She reports ER doctor is unsure if he had a seizure. She reports pt had blood work done while in the hospital, and theses results were normal. She reports he'd not had any vaccines since is last hep B #2 10/28/02. She reported that his psychiatrist put him on Vistaril and Paxil for anxiety two weeks ago. She called the psychiatrist to determine if Vistaril and Paxil could have contributed to his dehydration and he thought not. She also reported to me that if it happens again, she will have a CAT scan run because her father died at age of 29 of a cerebral hemorrhage, and this possibility concerns her, and her brother has a history of migraines. 1/29/03 10:40am, TC to mom to determine if ER doctor who saw pt was aware he received a hep B vaccine just prior to incident-no answer. 10:45am TC aide reports she does not think mom thought to report this to the ER doctor as they talked about this later, and she reports she does not think mom reported this to the ER doc. TC ER they report child not seen there yesterday; TC ER they report child not seen there. TC urgent care not open until noon. 11:45 TC mom-no answer, left message to call me. 3:40pm TC urgent care they report he was not seen there. TC-mom answer machine on -did not leave message. 1/29/03 3:40pm TC urgent care not seen there. 3:43 TC mom-answer machine on-no message left. 2/3/03 9:10am TC mom to see how her son is doing and to determine if she did inform the ER doctor that pt received his hep B injection just prior to the incident at school on 1/27/03.  She said she did tell the ER doc, and then proceeded to tell me that pt has experienced further problems. She reports that on 1/29/03 he had three more incidents at school and that the school said they could have been seizures but they were not sure, that he "fell" three times. She reports she took him to ER that day 1/29/03, and on 1/27/02. She reports he was admitted and stayed for three days. She reports MD at hospital treated him. She reports he was placed on medications Neurontin and Midrin. She reports he had two episodes on 2/2/03 and one this am. She reports she wants him seen at other hospital and plans to take him there for evaluation. We discussed the possibility of episodes being related to the hep b vaccine. She reports he was a boxer for three years and thinks it could also be from this. She reports he wore headgear during his boxing. I suggested that if she'd like, I could get her the phone no. to the traumatic brain injury coordinator and could maybe visit with her about this possibility. She asked for his number, for which I gave it. To reiterate, I asked her again if she did inform the first ER doctor on 1/27/03 of pt's getting the hep B just prior to being seen on 1/27/03, and she reports she's not sure but reports that she did inform the ER doc on 1/29/03, the day he was admitted. 2/3/03 completed and mailed VAERS report.