Age: 84.0
Sex: F
Vaccine: FLU3
Symptoms: Stress, Tobacco abuse, Type 2 diabetes mellitus, Urticaria
Clinical narrative: Initial unsolicited report was received from a nurse on 02 March 2015. A female patient (date of birth not reported) with no reported past medical history had received on 17 September 2014 a right arm injection of FLUZONE HD (lot number and route were not reported) and immediately had pain in the right arm. According to the patient, she felt that the vaccine was administered improperly. The patient required an ER/doctor visit and was treated with a steroid shot in the right arm on 02 March 2015. According to the physician, they agreed "that it may have been given too low on the deltoid resulting in the right arm pain". The patient continues to have right arm pain. Outcome is not recovered. Documents held by sender: none. Follow-up information received from the physician on 31 March 2015: Allergies. Patient was allergic to Penicillin G and on Codeine she experienced vomiting. Concomitant medications included aspirin 325 mg 1 tablet every day by oral route entered on 14 May 2013, ATIVAN 0.5mg 1 tablet every day by oral route stress prescribed on 26 Jan 2015, CHANTIX continuing month box 1 mg 1 tablet twice a day by oral route prescribed on 26 Jan 2015, enalapril maleate 10 mg 1 tablet every day by oral route filled on 19 Jan 2015, FARXIGA 5 mg 1 tablet every day by oral route prescribed on 26 Jan 2015, hydrochlorothiazide 25 mg 1 tablet every day by oral route filled on 05 Dec 2014, magnesium oxide 400 mg 1 capsule every day by oral route prescribed on 25 May 14, metformin 500 mg 1 tablet twice a day by oral route filled on 05 Dec 2014, omeprazole 20 mg delayed release capsule by mouth every day renewed on 19 Jan 2015, omeprazole ER 20 mg extended release 1 capsule every day by oral route prescribed on 27 Jan 2014, ONE TOUCH Ultra Test strips use one strip to check glucose twice daily as needed prescribed on 13 Jun 2013, ONE TOUCH ultra-soft lancets use to check glucose twice daily and as needed prescribed on 13 Jun 2013, Oxybutynin chloride 5 mg take one tablet by mouth every day renewed on 19 Jan 15, prednisone 20 mg take 2 tablet every day by oral route for 5 days filled on 31 Oct 2014, simvastatin 20 mg take one tablet by month every day filled on 19 Jan 2015. Problems: Problems not reviewed (last reviewed 10/18/2013), Intestinal infection due to Pseudomonas, Diarrhea of presumed Infectious origin, Tinea pedis, Malignant melanoma of skin of trunk Onset: 02/10/2011 - right upper chest wall, Primary malignant neoplasm of bladder, Type II diabetes mellitus uncontrolled, Vitamin D deficiency, Pure Hypercholesterolemia - Onset: 03/03/2005, Hyperlipidemia, Hypomagnesaemia, Anemia, Dysthymia Onset: 08/23/2005, Tobacco dependence syndrome - Onset 03/03/2005 uses cigarettes intermittently - quit 3/2011, Primary insomnia, Feeling stressed, Neuropathy, Cataract, Benign essential hypertension Onset: 08/23/2005, Transient cerebral Ischemia, Atherosclerosis of arteries of the extremities, Intermittent claudication, Gastroesophagneal reflux disease, Barrett's esophagus, Constipation, Steatosis of liver, Disorder of kidney and/or ureter, Acute cystitis, Rosacea, Urticaria, Disorder of skin, Osteoarthritis - Onset: 11/04/2004, Hip pain, Knee pain, Joint pain in ankle and foot, Disorder of bursa of shoulder region - Onset: 11/01/2005, Plantar fascial fibromatosis Onset: 12/09/2004, Disorder of bone and articular cartilage, Osteopenia, Insomnia, Diarrhea, Dysuria, Urge Incontinence of urine, Injury of carotid artery, Patient had tumor in bladder 2007. Patient states she sees urologist every 6 months. Surgical History: Surgical History not reviewed (last reviewed 10/10/2013), colectomy - R due to colon CA at age 61, hysterectomy TAH with SSO due to fibroids, oophorectomy - due to ectopic pregnancy, appendectomy; Cystoscopy - 04/07/2011, Diagnostic colonoscopy - 04/26/2010, EGD biopsy single/multiple - 04/28/2010, cystopexy x 2. Family History: Family History not reviewed (last reviewed 11/02/2014), Mother - Acute myocardial infarction (died age: 90) - Chronic obstructive pulmonary disease - Cataract, Unspecified Relation - Family history of genetic disorder carrier (died age: 17) - Grand-daughter geleophysic Dysplasia-genetic disorder, Brother - Malignant tumor or prostate - 70y Alive, Son - Personal history finding - Diabetes mellitus - Malignant tumor of renal pelvis (died age: 50) - RCC died 4/30/08, Sister - Malignant tumor of colon (died age: 76) - Died 02/21/2006 - Intracranial aneurysm, Son - Motor vehicle accident victim (died age: 21), Father - Cerebrovascular accident, Two children with history of diabetes. Social History: Social History not reviewed (last reviewed 10/10/2013), Family Medicine Adult and Preventative Health, Advance directive: Y (Notes: Daughter is her HCProxy). Alcohol intake: Occasional (Notes: 1/month). Smoking Status: Former smoker (Notes: stopped smoking 2nd week in August 2013). Chewing tobacco: none. Occupation: retired (Notes: homemaker raised 9 kids). Sexual orientation: Heterosexual. Members of household: 3 (Notes: lives with daughter and son in law). Marital status: Widowed. Number of children: 9+ (Notes: grandkids and great grandkids). Exercise level: Moderate (Notes: walking daily). Diet: Regular. Caffeine intake: Moderate (Notes: 2 cups daily). Pap smear: (Notes: always normal no need at this time). Cholesterol/HDL Screen: 07/05/2012 (Notes: Cholesterol 119, triglycerides 144, HDL 34.0, LDL 56.2, RF 3.50). Tetanus/ADACEL Vaccine: 11/16/2006 (Notes Td). Colonoscopy Screen: 05/09/2012. Mammography Screen: 02/05/2014 (Notes: code 2 neg Athol). PNEUMOVAX Vaccine: 03/31/2008. Bone Density Screen: 02/01/2013 (Notes: spine nl osteopenia hip). GYN History: GYN History not reviewed (last reviewed 10/10/2013), Gravida: 9. Para: 9. Term births: 9. Preterm births: 0. Abortions: none. Living children: 9. History of abnormal pap: No. ROS: Constitutional: Patient notes no fevers, chills, headaches, swollen glands, or night sweats. Eyes: Patient notes no tearing, drainage, blurred vision, double vision, loss of vision, eye pain, or light sensitivity and abnormal last eye exam (6/3/14 retinopathy R mild L). Cardiovascular: Patient notes no chest pain or pressure; no cough, palpitations, shortness of breath, or edema; exercise intolerance (R arm pain worse again) and leg pain with exercise; and normal heart rate. Respiratory: Patient notes no cough, wheeze, shortness of breath, or chest pain. GI: Patient notes no nausea, vomiting, or diarrhea. Endocrine: Patient notes no change in hair or skin texture, thirst, hunger, or urination and no tremor or temperature intolerance. Neurologic-Brief: Patient notes no loss of bladder control or bowel control, no dizziness or vision changes, and weakness (when the pain is bad they had feels weaker); shooting pain down the R arm to site of injection. Integumentary-brief: Patient notes no rash, itching, bruising, or skin breakdown. Results /Interpretations: Fecal occult blood x 2, stool, Result: negative, Fecal occult blood x 3, stool, Result: negative, Fecal occult blood, stool, Result: negative. Physical Exam: Patient is an 84-year-old female. Constitutional: Patient is well developed, nourished, and appearing and overweight and in mild distress. Eyes: Conjunctiva noninjected, lids normal, and anicteric sclera. ENMT: Ears: well formed. Oropharynx: Normal, moist mucosa and Normal tonsils. Neck: Inspection/Palpation: No scars, masses, asymmetry, JVD, and carotid bruits bilaterally and Supple. Thyroid: No thyromegaly, tenderness, nodules, and asymmetry. Respiratory: Respiratory effort: No respiratory distress. Auscultation of lungs: No wheezes, rhonchi, and crackles and Good air movements. Cardiovascular: Heart: No rubs, gallops, and murmurs and RRR. Extremities no cording, varicosities, edema, or PVD skin changes. Peripheral vascular exam: No cyanosis. Integumentary: Inspection: No jaundice, cyanosis, lesions and rash. Neurologic/Endocrine: Neurologic: General: No focal neuro deficits and Grossly normal mental status; FROM but has pain with some triceps movements. Cerebellar: Grossly normal. Psychological: Mood/Affect: Appropriate affect. Assessment I Plan; Neuropathy - Discussed it was possible a nerve hit by the needle or there was swelling that was compressing a nerve. Had some limited success with a steroid injection: Mononeuritis of unspecified site. Anesthesia pain clinic - Right arm pain after a vaccination did not respond to NEURONTIN but did respond to a steroid shot. Type II diabetes mellitus uncontrolled- BS and HA1C are reviewed and are not with goal range. Lipids are at goal and were last checked. Blood pressure was at goal. Has insomnia and difficulty sleeping and some neuropathy pain will use NEURONTIN to help her to function. Creatinine and microalbumin are at or below goal. Tobacco dependence syndrome - Had started smoking again with the stress. Benign essential hypertension. High blood pressure: after your visit. Gastroesophageal reflux disease- Using omeprazole and a probiotic. Feeling stressed- Not sleeping well and feeling stressed. Urticaria Long talk about urticaria recommended CLARITIN during the day and BENADRYL at night working through and processing her stress. Upon internal review the case was considered serious due to important medical events (neuropathy). Documents held by sender: none.