Age: 54.0
Sex: F
Vaccine: FLU3
Symptoms: Adverse drug reaction, Injection site pain, Injection site swelling, Injection site warmth, Musculoskeletal pain
Clinical narrative: 9/25/09 Chief complaint: right arm pain/swelling s/p flu shot. HPI: patient came in today because of pain and swelling of the right upper arm after she got a flu shot yesterday. Patient was doing well after injection and then about 4 hours after patient has noticed increasing pain on the right upper arm area, not from the injection site but the whole upper arm including the right shoulder area, armpit, right side of the neck, and shoulder area. Patient denies any systemic symptoms. No fever, chills, or any rash. Patient denies any pruritus. Patient is feeling better today than yesterday. The swelling on the under side of the upper arm as well as the armpit area has improved. The pain has improved as well. Patient has been taking over the counter and says. Patient had flu shots in the past without any problems. Patient has no chest pain, shortness of breath, or any active cardiopulmonary symptoms. Patient has no abdominal pain, diarrhea, or vomiting. Patient has no active GI or GU problems. Appetite good, no fevers, night sweats or weight loss. No chest pain, shortness of breath or peripheral edema. No cough, wheezing or dyspnea. No nausea/vomiting, abdominal pain, or change in bowel habits. No dysuria, urgency or incontinence. No MS changes, no motor weakness, no sensory changes. BP: 110/82, HR: 76b/min, resp: 16 r/min, temp: 98.2, height: 63 in, weight: 156 lb, BMI: 27.6 kg/m2, BSA calculated: 1.74, BMI calculated: 27.63. GENERAL APPEARNCE: appears stated age, well appearing, NAD. HEENT: PERRL, EOMI, TMs normal, oropharynx clear. R UE: positive warm, swelling and tenderness on the R deltoid area, injection site (puncture site), no evidence of infection or cellulitis; there is tenderness on the R shoulder area and inner aspect of the upper arm, there is some tenderness on the R armpit but no swelling or tenderness. NECK: supple, no JVD, no tenderness on spinous process, slight tenderness on the lateral aspect of the R neck (lower portion), ROM of the neck is nl. LUNGS: clear to auscultation and percussion. HEART: normal S1, S2 without murmurs, gallops, or rubs; PMI not displaced. ABDOMEN: NABS, soft, non-tender, without hepato-splenomegaly. EXTREMITIES: without clubbing, cyanosis, or edema, no acute jt inflammation or involvement. R SHOULDER: grossly nl, no acute inflammation, ROM is limited up to 120 degrees on abduction, forward flexion due to pain on the upper arm, rotational motion is nl. NEUROLOGIC: alert and oriented x 3, cranial nerves II-XII intact, motor/sensory exam normal, DTRs symmetric, normal gait. Assessment: adverse effect of drug therapy. Plan: patient has soft tissue inflammation secondary to flu shot. There is no evidence of cellulitis or infection. Cold compress for 24 hours and then after that warm compress continue NSAIDs. Monitor for signs and symptoms of infection, start BACTRIM if develops any cellulitis or infection return to clinic if any worsening symptoms on Monday and , both of the ear in the weekend if worsen starch range of motion exercise in 48 hours.