Sex: M
Vaccine: HEP
Symptoms: Irritability, Jaundice, Ocular icterus, Otitis media, Pyrexia
Clinical narrative: Information has been received from a physician via pediatric medical records and the following experience was identified concerning a 3-day-old male newborn with lacrimal duct obstruction congenital (WAES # 0803USA01840) as concurrent condition.  The patient was born via spontaneous vaginal delivery at term on 08-NOV-2008.  No known allergies were reported.  No 08-NOV-2008, the patient was vaccinated with the first dose of RECOMBIVAX HB (manufacturer unknown, lot number, injection route and site not reported).  On 11-NOV-2008, the patient was brought in by mother with concerns about him becoming jaundiced.  He was born on the 08-NOV-2008 and dismissed from the hospital on 10-NOV-2008.  His mother stated that he had 5-6 dirty diapers since being dismissed, and had 7-8 wet diapers.  He was being breast fed about every 4 hours at the time.  Physical examination showed:  the patient's weight was 6 pounds and 14 ounces on 11-NOV-2008.  He had lost 10 ounces comparing to 7 pound 8 ounces at birth, which was still under 10% weight loss.  He had jaundice noted to the sternum.  Some scleral icterus was also noted.  Total bilirubin test drawn at the hospital on 11-NOV-2008 was 15.4, with direct 0.2 and indirect 15.0.  Assessment was physiologic jaundice.  The physician explained the diagnosis to the mother and suggested her to start waking him up for feeding every one and half hours to 2 hours.  Instruction included placing the newborn near a window in the sunlight and follow-up in one week for weight check or sooner if questions or concerns arise.  On 14-NOV-2008, follow-up visit showed that the patient has not had any lethargy or cyanosis and they stated that his jaundice was improving.  PE was within normal limit except for jaundice to the neck.  His bilirubin was 16.3 on 12-NOV-2008 ("2 days ago") and was 16.6 on 13-NOV-2009.  A newborn bilirubin test was scheduled on 14-NOV-2008 without results reported.  Another visit on 12-DEC-2008 where a physical examination was performed showed that there was no jaundice, cyanosis or bruising on skin.  On 12-DEC-2008, the patient presented to the clinic with his mother for evaluation of some spitting up.  After every feed, he spit up and was quite fussy.  He was doing well otherwise.  He was breast feeding every 3 hours and has not had any fevers, illness or problems with constipation.  Assessment was gastrooesophageal reflux disease (GERD).  Planned treatment for GERD included ZANTAC 15mg / ml syrup, 0.5 ml PO BID.  Therapy with ZANTAC for GERD was continued on 02-JAN-2009.  On 22-JAN-2009, the patient presented to the clinic with his mother for evaluation of a fever which he has had since 21-JAN-2009 ("last night").  He also had a nonproductive cough and purulent rhinorrhea started on 20-JAN-2009 ("for the last 2 days") as well.  No wheezing or any increased work of breathing was noted.  He has not had any lethargy.  His body temperature was 99.9 degrees Fahrenheit, pulse was 130 per minute and respiratory rate was 32 per minute.  Physical examination found purulent rhinorrhea, left tympanic membrane erythmatous and right tympanic membrane clear.  Assessment was left Otitis media.  Treatment for him included AUGMENTIN suspension 6ml BID for 10 days and carbinoxamine maleate (+) dextromethorphan hydrobromide (+) pseudoephedrine hydrochloride drops 0.25 ml QID PRN.  On an unspecified date the patient recovered from the events.  On 03-MAR-2009, the patient received the second dose of RECOMBIVAX HB (manufacturer unknown, lot number, injection route and site not reported).  His immunizations, including a dose of PENTACEL and PREVNAR on 11-FEB-2008, were all up-to-date.  Additional information is expected.