Age: 0.41
Sex: M
Vaccine: DTAP, HIBV, IPV, PNC
Symptoms: Cough, Crying, Ear pain, Musculoskeletal stiffness, Nasal congestion
Clinical narrative: See attached documentation. 2/7/05-Mom brought patient in for 5 months shots.  Mother voiced concern to nurse about Dtap shot since patient had a very bad reaction the last time.  Told high fever and crying was normal reaction.  Gave patient 2nd shot. Within a half hour of bringing patient home he started crying and screaming.  He would go very stiff.  Did not stop crying for three days. After three days he finally fell asleep. When he woke up he would not respond to the sound of parents voice, would not respond to his favorite toys, just stare into space.  He did not cry or make noise, and had very minimal movement.  Before this, he was a very smiley happy baby, that responded to his environment. Patient had gotten his shots on Monday. Mother called doctors office and was told to give him Tylenol, that he was a normal reaction to the shot.  By Friday, patient still was not responding, mother called Drs. office and got the service, when Dr. finally called back, he said he doubted that shot was giving him this reaction.  That it was highly unlikely, and to bring him in on Monday.  2/14/05-Pt. brought in and Dr looked at him over and said he was fine. Mother explained to Dr. that he was not responding like he did before Dr gave him the  shots.  He said he looked fine and sent us home. 2/15/05-Mother spoke to Dr that took care of Aunt for 45 years. He told mother that under no circumstances is patient to receive another Pertussis vaccination.  He even wrote a letter on parents behalf stating this reason for this decision. He asked me to have the other Dr. call him so they could discuss this matter. The other doctor refused. 3/29/05- Mother called Dr.'s office today, because pt. has a Drs. appt on April 7.  Spoke to nurse and told her that under no circumstance is he to have his third DPT shot.  She said she had to talk to the Dr. and would get back to me. She called me back and said the Dr. would not treat patient if did not give him a shot. Mother explained to nurse that the parents do not have a problem with patient receiving all the other vaccinations just not the DTP.  4/7/05-Brought patient in to get his other vaccinations, we gave Dr. a copy of letter the other Dr. sent us. He stated he still does not believe patients reaction was to the DTP. He had husband sign a waiver saying refusing the DTP shot. 8/2/05 Brought patient in because he has a severe congestion, coughing, fever and loss of appetite. The Dr gave him a prescription for cough medicine and antibiotics.  9/27/05- had to take patient to ER-vomiting, high fever and congestion.  They told us to give him Amoxicillin and Motrin.  9/29/05-Broguth him to Dr for follow up, told mother to continue treatment and gave me more prescriptions. 10/10/05 Brought patient in for his ear infections, gave us a different antibiotic to give him. Pt. still congested and has runny eyes, still will not stop coughing. 10/19/05-Follow up visit, gave him another antibiotic, still has ear infection.  11/18/05-Brought pt. in for flu shot, still has ear infection, still congested. Continued antibiotic treatment. 1/4/06-Brought pt. in for second half of flu shot and final vaccinations until he's four. Still has runny nose and severe coughing. Dr said ears looked good.  Mother voiced concern that still is not walking or crawling at 16 months old. He said he would get me a referral for a pediatric Neurologist. 1/6/06 Called Dr.'s office to find out if they had my referral. They told me they still have not gotten approval from my insurance company. They would call me when they had it. 1/9/06 Called Dr.'s office to find out if they had my referral. Spoke to nurse, she said they had to refax all the paper work since their county does not have a pediatric neurologist and that they would have to go to Tampa or Orlando. 1/12/06- Called the Dr.'s office again and spoke to nurse, she said she had to fax the papers again on Wednesday morning 1/11. That she should have the referral by 1/13 (tomorrow). 1/13/06- Called Dr. office and got the service at 3:02pm. Pt. has high fever of 104.6, no other symptoms. Mother called service again at 6:15pm and at 11pm. Mother finally asked the service why a docter has not called me back. She has a supervisor check the records, verified that she had called. The on call Dr. told me to alternate Tylenol and Motrin. He could not tell me why someone had not called me back. Told me pt. needs to be seen on Monday. By Monday his fever broke. Saturday night when I came home from work his fever was 105.4. 1/16/06 Called Dr.'s office again today. Spoke to one of the nurses, she told me other nurse is still working on it. I explained that it had been 12 days and she said that how it goes. I called husbands Pediatric Neurologist Dr. office and they recommended that I call this other Dr.  I made an appointment for Feb 22. I called insurance company, they said no problem have the other Dr. office call them and we'll get it approved.  I also called other Dr.'s as well and made an appointment for patient for Thurs 1/19 for his chronic ear infections. 1/16/06 Mother went and picked up a copy of pt. file from the Drs. office. I told the two nursed that I had called the service several time on Friday for pt.'s fever and no one ever called me back until 11:30pm. They really did not say anything but gave me blank stares.