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Administered by: Unknown Purchased by: Unknown
Life Threatening? Yes
Write-up: Patient received rotavirus vaccines on 11/29/2006 and 1/22/2007. Patient presented on 4/21/07 with a 1 day h/o episodic fussyness, vomiting a few times, clingy, tired between episodes, pale. Seen in clinic 5 days prior with cold symptoms and fever and diagnosed with an AOM and placed on amoxicillin. Had a few day h/o diarrhea without blood a few days ago which resolved. Cold symptoms improving. Barium enema revealed intussusception from ileocecal area completely through ascending colon which reduced 1/3 of the way. Life flight to hospital where peds surgeon reduced with air enema. 6/12/07 Received medical records from PCP which also included ER records & vax records. Patient experienced abdominal pain, nausea/vomiting & diarrhea & was not acting himself since awakening from nap on 4/21/07. Insoncolable crying & decreased activity. Parent reported fever approx 3 days prior & was on antibiotic since 4/16 when dx w/acute otitis media. Exam revealed slight eye discharge. Abdominal x-ray revealed IS. Patient transferred via helicopter to higher level of care for probable surgery. PCP records indicate IS was reduced w/air enema. VAX record: Does not include vax lot numbers. Vax received at Health Department. Will request from them. PCP Records: Patient had extensive port wine stain over lower back down to feet & had US of lower spine to eval which was reported as WNL. Had normal newborn labs. Experienced dry skin, viral URI, fussiness, keratosis pilaris w/mild atopic dermatitis, diaper rash, bronchiolitis, bilateral otitis media, heart murmur. Leg length & circumference was unequal & referred to ortho specialist. On 4/16 dx w/left acute otitis media & started on antibiotics. 06/13/07-vac rec received. VAERS updated with information and record faxed to CDC. 6/19/07 Received hospital medical records which reveal patient was transferred from outlying ER for incompletely reduced IS. Patient had become very lethargic after vomiting. Mass was still palpable in RUQ & air contrast enema was repeated successfully. Had a bloody stool & vomiting s/p enema. Kept overnight for observation & d/c home next am. FINAL DX: ileocolonic intussusception, reduced by air enema.
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