Received Dec 29, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| DTAPHEPBIP | DTAP + HEPB + IPV (PEDIARIX) | GLAXOSMITHKLINE BIOLOGICALS | 2 | 2TP34 | IM / RL |
| HEP | HEP B (ENGERIX-B) | GLAXOSMITHKLINE BIOLOGICALS | 3 | 2TP34 | ID / RL |
| HIBV | HIB (HIBERIX) | GLAXOSMITHKLINE BIOLOGICALS | 2 | 5474P | IM / RL |
| PNC15 | PNEUMO (VAXNEUVANCE) | MERCK & CO. INC. | UNK | Z011814 | IM / LL |
| RV1 | ROTAVIRUS (ROTARIX) | GLAXOSMITHKLINE BIOLOGICALS | UNK | Z009603 | PO / MO |
MOTHER STATES THE PATIENT HAD A SEIZURE AT HOME LATER THAT DAY 12/4/25. MOTHER STATES SHE WAS INSTRUCTED NOT TO GIVE ANY TYLENOL FOR 6 HOURS POST VACCINATION DURING VISIT AT PEDIATRIC OFFICE.
NO ILLNESSES, NO FEVER AND CLEARED FOR VACCINATION BY DOCTOR
Patient was previously seen by Dr. for concerns regarding weight gain and feeding difficulties. The infant had developed a feeding aversion where he would turn his head away from the bottle and cry when placed in feeding position. Mother reports that previously he would take four to five ounces every three to four hours on a regular schedule, but then stopped showing interest in the bottle. When feeding was pushed, the aversion worsened significantly. Mother implemented a baby-led feeding approach based on the Rowena Bennett method, allowing the infant to lead feeding times and not offering again for three hours if initially rejected. This approach helped him regain trust with feeding. Currently, total daily intake varies significantly, ranging from 13 ounces on worst days to 26 ounces on very good days, with typical intake around 24 ounces. He takes variable amounts per feeding, sometimes two ounces, sometimes four to five ounces, every 3.5 to 4 hours. He wakes at night to feed when hungry. Mother noticed increased coughing, sneezing, and hiccups occurring twice daily, which prompted the previous visit. Weight had dropped to 11.2 pounds on 10/21/2024, remained at 11.10 pounds on 11/10/2024, then increased to 11.8 pounds on 11/17/2024. Current weight shows continued improvement with reasonable weight gain of 10 ounces since last visit.
Famotidine 0.35 mL once daily for acid reflux
NKDA
PT WAS TAKEN TO HOSPITAL AND LUMBAR PUNCTURE, VARIOUS LABS AND HEAD CT WERE DONE BUT ALL CAME BACK NEGATIVE. PT WAS TRANSFERRED TO ANOTHER HOSPITAL WHERE THEY ARE ABLE TO TREAT PEDIATRIC PATIENTS. AN EEG WAS ORDERED BUT RESULTS WERE NOT RECORDED PROPERLY OVER NIGHT. PT WAS THEN TRANSFERRED TO A THIRD HOSPITAL WHERE AN EEG WAS DONE. PT WAS PUT ON KEPPRA AND WILL REMAIN ON THE MEDICATION X 3 MONTHS AND THEN WILL NEED TO BE ASSESSED. DUE TO PATIENTS AGE, THE HOSPITAL SAID THEY ARE NOT ABLE TO DIAGNOSE HIM WITH A FEBRILE SEIZURE BUT THEY FEEL IT WAS A SEIZURE DUE TO THE RISE IN BODY TEMP. PT WILL NEED TO SEE NEURO AGAIN.