Received Sep 11, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| TDAP | TDAP (BOOSTRIX) | GLAXOSMITHKLINE BIOLOGICALS | 1 | H4K3S | IM / RA |
on 09/08/2025 mom called to report "mom called and said that patient had a reaction to the vaccine given in her right arm (TDap) given on 09/08/2025. She stated that she had hives up her arm and on her neck she stated that two benadryl were given last night and that helped with the reaction but today she didn't wake until 10am and she's unusually tired. She stated where the injection was given is hot to the touch. She is wanting a call back from the nurse, please. No benadryl given today" . Dr called and spoke with mom on 09/09/2025 at 4:11pm stating "Discussed with mom. Arm still itchy and red, warm to the touch...but no other associated signs/symptoms. No systemic symptoms. If worsening, she will take her to the ER. If still red/warm/itchy/etc...she will bring her to walk-in clinic in the morning. Will you see what we need to do with respect to reporting from a vaccine reaction standpoint?" Sent to office manager who states "Please report to VAERS and do an ERS with a f\u phone call today to check how the child is doing." Patient into walk in clinic on 09/10/2025 at 09:00am vitals 44.2kg for weight, temp 97.3, respirations 18, pulse 86 and bp 112/74, pain 0, oxygen 98%. Dr evaluated patient and noted "Here with mom for f/u after rash that occurred on her right upper arm and neck after vaccines that were received on 9/8. Mom says the rash has essentially resolved. No face/mouth/lip swelling, no respiratory symptoms. No other systemic symptoms. Patient says her right arm still itches somewhat. No benadryl given since yesterday, still receiving famotidine bid to complete full 5-day course. Of note, mom has numerous allergies and patient has had allergies with amoxil and augmentin in the past." . Mom brought patient back into the office on 09/10/2025 at 11:46am for shaking. vital signs Vitals Temp: 98.3*F RR: 18 Weight: 44kg BP: 105/71 O2: 98% Pulse: 92 (Highest 106. Patient then evaluated again by Dr stating "Patient seen in clinic for f/u, also refer to visit from earlier this morning. Mom says that after leaving clinic this morning, they were sitting at store and patient had a new generalized tremor, with this lasting 2 minutes or less. No generalized tonic/clonic movements. No AMS. No LOC. No loss of bowel/bladder control. She did eat breakfast, no meal skipping. No recurrence of rash that was noted as potential side effect from vaccines that were received 2 days ago. She has had no further episodes since then and continues to act normally at time of re-examination circa 1145 this morning. Repeat exam at this time was also normal, including normal neurologic exam. No new findings. Mom to watch closely for new sick symptoms or further episodes of any kind...with any of these changes meaning that she would have to go directly to the ER. During re-exam, patient was writing in her notebook and when I asked her to raise her eyebrows during her neuro exam...she essentially batted her eyebrows as an act of physical comedy, which made both her mother and myself laugh. -- I'm not convinced that this is a true sequela/reaction from her vaccines, but when the previous vaccine reaction is reported, this should still be added to that case in the interest of completeness". On 09/11/2025 at 02:50pm I called mom to follow up on patient, mom said "she is doing well today. " Mom asked patient "is your arm still red?" Patient states "no, it is not red just a little itchy".
none according to well visit with Dr on 09/08/2025.
asthma
none
amoxicillin, augmentin