Age: 54.0
Sex: F
Vaccine: FLU3
Symptoms: Decreased appetite, Dysphonia, Fatigue, Full blood count normal, Headache
Clinical narrative: 55 y/o (currently) female who reports receipt of inactivated influenza vaccine (IIV) mid-late SEP 2012, on a Friday. (Immunization records report 2012 IIV dose administered on 5 NOV, but 1 OCT 2012 Occupational Health notes supports receipt of IIV in SEP 2012). No other vaccines were received on that day. Patient reports that there was nothing unusual about vaccine administration. She denies any significant swelling, redness, tenderness, bruising, or itching at vaccination site. She did not experience facial, mouth or throat swelling, itching, rashes, dyspnea, GI-related symptoms, or blacking out within the first 48 hours after vaccine receipt. Approximately 24 hours after vaccine receipt, patient experienced a sore throat and generalized achiness in her joints. She measured her temperatures at that time, and they initially ran around 99.8; within 24-48 hours, her temperatures peaked around 101. She also developed frontal headaches, described as a pressure sensation above her eyes, with no associated photophobia. Patient experienced decreased appetite, severe fatigue, and later developed a persistent dry cough. At symptom onset, she pushed oral fluids and rested. When the headaches and cough persisted, she self treated with TYLENOL and HUMIBID. After resting over the weekend, she thought she felt well enough to return to work, but after a few days, she began feeling worse. She did not seek evaluation at the time, but she felt bad enough that she stayed home from work x 3 days. The symptoms persisted for 2-3 weeks, with gradual improvement after the first week. During her visit to Occupational Health on 1 OCT 2012, there was mention of URI symptoms developing around 19 SEP, following receipt of flu vaccine - (body aches, sore throat, neck fullness, hoarseness, headache, and cough with temperature up to 100.4). ASSESSMENT: 1. Agree with full duty as patient has no fevers. Given patient had a sick contact, it is difficult to attribute her development of URI symptoms to a killed virus vaccine she received 2 weeks earlier. No plans to submit workman's comp or VAERS report on the patient's behalf. 2. Coughing up sputum yellow: 54 y/o woman developed URI which has persisted for 3+ weeks. Patient had sick contact at work. Patient now improving and able to work since last Thursday. Persistent cough most likely attributable to post nasal drip. Labs showed normal CBC. Patient had prior TST conversion s/p INH therapy. Plan to obtain CXR to R/o active process and patient planning to see PCM if symptoms persist. Wet read from CXR showed no focal consolidation, but potential peribronchial cuffing potentially suggestive of viral process. Patient describes her overall health as pretty good. Since 1 OCT 2012, she has had no persistent recurrence of symptoms experienced following vaccine receipt. Patient was feeling fine on the day of vaccine receipt and denies symptoms of infection antecedent to or on the day of vaccine receipt. She reports an allergy to COMPAZINE, tongue swelling and joint stiffness. She has no known allergies to foods, latex, insect stings, or seasonal allergies, and no history of asthma, eczema, or hay fever. Patient has no history of previous adverse events following immunizations (AEFI). She has received several previous IIV vaccines without problems.