Age: 66.0
Sex: F
Vaccine: PPV
Symptoms: Crying, Decreased appetite, Fatigue, Hypoaesthesia, Injected limb mobility decreased
Clinical narrative: 10/31/2017, 4:31 PM: Patient's husband called - He states patient received her pneumo shot this morning in the office and that about 2 hours later she felt a great deal of pain from where she got her injection. He states she is unable to lift her arm, she complains for feeling very tired and is crying. He states he hardly ever sees his wife cry so that he knows she is in a great deal of pain. He states the site looks normal, it's not red or raised up. Please advise, thank you. MD, 4:56 PM- Recommend a warm compress to the area, Take 650mg TYLENOL and 25mg BENADRYL now and keep it up for the next 24 hours. This can be reaction to the vaccine, Should improve after 24hours. MA, 5:05 PM, PC to pt, pt and pt spouse advised per Dr. message: Recommend a warm compress to the area, Take 650mg TYLENOL and 25mg BENADRYL now and keep it up for the next 24hours. This can be a reaction to the vaccine, Should improve after 24hours. Pt and spouse voiced understanding and requests Pneumococcal Vaccine VIS statement be faxed to them at their home fax. MA, 5:08 PM, Pneumococcal Vaccine VIS and Copy of Demographic with Pneumococcal information faxed to pt. November 1, 2017, 9:24 AM, Spoke with pt and pt spouse this morning (speaker phone) Pt states she did run fever last night 101. Still using the TYLENOL for pain. Did take 2 doses of BENADRYL. Pt states she did not eat dinner last night, just stayed in bed until 8:00am this morning. She was able to walk steady to the kitchen and has had some coffee. Fever has passed. Numbness from elbow to finger is gone. Still having pain from shoulder to elbow. She does feel like she has turned the corner but still in pain. Pt concerned if this vaccine could cause Guillain Barre Syndrome like flu shot? Pt states she will contact number in VIS sheet to report adverse reaction. Offered pt appointment with Dr. for Friday 11/03/2017, declined at this point. Pt advised I will call her in the morning to check and see how she is doing and can schedule for Friday if needed. Pt advised I will forward message to Dr., if Dr. has any additional information I will call her back otherwise I will call her in the morning to check on her. Pt and spouse voiced understanding and advised to call if any problems. MD, 10:20 AM, Noted, No further recommendations at this time. November 2, 2017, MA, 9:28 AM, Spoke with pt, pt states she has improved clearly in the last 24 hours. She was able to get up and about yesterday, paid credit card bill. Overall feeling better just the arm is sore from the shoulder to the elbow. Pt states she tried to sleep different last night and even laid on the shoulder for part of the night, it hurt at first but then she went to sleep. Pt advised I will call her in the morning to check on her to see if she needs to see Dr. before the weekend. Pt voiced understanding. November 3, 2017, MA, 9:49 AM: Spoke with pt, pt states doing much better today, feels like you would the next after getting a vaccine. Little soreness in the arm, she did take TYLENOL this morning and only 2 doses TYLENOL yesterday. Pt states full range of motion, no wincing pain. Pt was going to report adverse reaction form but I advised pt I would submit form regarding vaccination. Pt states symptoms started day of vaccine about 3pm, highest fever 101.4 within 24 hours, 18 hours in bed, did not eat for 18 hours, did cause pain, numbness and she did notice her hand was swollen. Reviewed information with pt. as I will need the information to complete adverse reaction paperwork.