Age: 18.0
Sex: F
Vaccine: MENB
Symptoms: Chills, Erythema, Musculoskeletal discomfort, Neck pain, Pain in extremity
Clinical narrative: Visit Information  Date/time: 8/13/2020 @ 08:21 am  Telemedicine patient location: Home  Appointment type: VIRTUAL VISIT  Telemedicine duration: 9 minutes    Chief Complaint  Rash REC TO VAC MEN B   VERIFIED NAME AND DOB.  INFORMED CONNECTION IS SECURE AND CONFIDENTIAL.  LOCATED AT HER HOME. REC. VERBAL CONSENT TO PROCEED WITH ENCOUNTER.  NOTICE NECK SWELLING AND TENDERNESS TO LEFT SIDE WITHIN THREE HOURS OF REC MENINGITIS B SHOT ON 8-11-20.  NKDA. TAKES PEPCID.  HAS TAKEN BENADRYL  X 2 YESTERDAY AND ONCE THIS AM  Telemedicine:    Verify Name and DOB  This is a completely secure and confidential encounter  Verbal consent to proceed with encounter   History of Present Illness  Patient received Trumemba yesterday and 3 hrs later began with swelling, pain and redness of neck. Scale of pain 6/10 pain now is 2/10; able to move neck side to side but with some discomfort. Area of neck was warm to touch and painful to touch and to move neck to the side. These symptoms developed in the first 36 hrs and at 48 hrs swelling has significantly decreased to mild; redness resolved with benadryl; patient did have temp of 99 in first 36 hrs none since.  Swelling was located over SCM muscle and anterior cervical muscle; it did not involve the jaw.  Arm of injection site was painful in the first 36 hrs pain level 7/10 now is 3-4 out of 10 and only mildly swollen, no redness developed.  Exposure to new soaps/detergents: none  Exposure to known allergens: none  Recent illness: none  Current/recent meds: reviewed   ROS Findings  Constitutional: Reports fever/chills: 99. Denies body aches, headache, fatigue, malaise, loss of appetite, not sleeping well, night sweats.   Respiratory: Denies daytime cough.   Cardiovascular: Denies palpitations, chest pain.   Gastrointestinal: Denies nausea, vomiting.    Patient History  Allergies History reviewed and updated as appropriate  Allergies Reviewed 08/13/2020 08:25:29  No active medication allergies or reactions  PEPCID  BIRTH CONTROL    Medication List Reviewed 08/13/2020 08:25:46    Allergies Reviewed 08/13/2020 13:05:55   Exam Findings  Constitutional: Normal general appearance: alert, pleasant, not ill appearing.   Eyes: Normal conjunctivae & lids: pink & moist.   Ears, Nose, Mouth, Throat: Normal nares: clear, no flare; lips, teeth and gums: no lip/oral swelling; oropharynx: moist mucous membranes, without pharyngeal erythema or mucous membrane involvement.   Respiratory: Normal respiratory effort: no retractions, no tachypnea, and no audible grunting or whezing.   Cardiovascular: Normal extremities: no edema, brisk capillary refill, with cooperation of patient/parent through video visualization of good perfusion with brisk capillary refill confirmed (asking patient/parent to demonstrate).   Musculoskeletal: ABNORMAL Findings: mild swelling over SCM of the left side noted with mild swelling of left arm over the deltoid area.   Skin: Normal inspection: no redness noted with video visit.    Assessment  Vaccine reaction  DX 1:  T50.A95A Adverse effect of other bacterial vaccines, initial encounter  DX 2:  T80.62xA Other serum reaction due to vaccination, initial encounter   Plan  History reviewed and exam considered with limitations acknowledged due to nature of virtual visit through a synchronous telecommunications system  No evidence of increased work of breathing or cardiovascular instability  Treatment is focused on symptomatic therapy: or antihistamines, stay cool  Call if no better 2-3 days, sooner for change/concerns or if spreads to mucous membrane surfaces or acting ill  To ER for tongue swelling/respiratory difficulty/wheeze/cough  Will report reaction to pharmaceutical inquire if cdc reporting is necessary.  Discussed under what circumstances a face-to-face office visit would be appropriate  Recheck in office prn/PE   Care Plan: Goals  ?pediatric preventive health management    Procedures  OV_EST_EXPANDED (20 MIN)