Age: 70.0
Sex: F
Vaccine: PPV
Symptoms: Anion gap increased, Basophil count normal, Basophil percentage, Blood calcium normal, Blood chloride increased
Clinical narrative: Doctors note from clinic visit on 11/12/19: Patient is a 70 year old female here following an allergic reaction to recent pneumovax immunization.  She got her immunization at the clinic at about 9 am last Friday.  By 3 pm she had swelling and was not able to lift her arm.  By the next morning, she had redness, swelling and rash at the borders of the reaction which was from elbow to shoulder on the left.  She presented to the ER and had an echo done which showed no emboli.  She was covered for infection with Keflex and allergic reaction is covered with benadryl and prednisone.  She has some side effects from the prednisone, and dry mouth from the benadryl.  Arm swelling is much improved, but not completely resolved.  Constitutional: No fevers or chills. No weight change.Continue prednisone and benadryl until completed and no longer reacting to immunization.  She will RTC if symptoms return with dc of meds.   Doctors note from ER visit on 11/10/19:Patient is a 70-year-old female presents emergency department for evaluation of left arm pain, swelling.  Symptoms reportedly started after she received a pneumonia vaccine on Friday.  She denies associated fever.  No shortness of breath or cough.,  Patient did report some tingling around her lips which she reports concern for for potential allergic reaction.  The symptoms have not resolved.  She denies history of similar reactions after immunizations in her past.  She reports no history of cellulitis or recurrent skin infections.  No history of DVT is reported. Medication Administration This Visit    Date/Time Order Dose Route Action   11/10/2019 0840 diphenhydrAMINE HCl (aka: BENADRYL) injection 50 mg 50 mg intravenous Given   11/10/2019 0840 methylPREDNISolone sod suc(PF) (aka: SOLU-MEDROL) injection 125 mg 125 mg intravenous Given   11/10/2019 0841 raNITIdine (aka: ZANTAC) 50 mg in sodium chloride 0.9 % (NS) 20 mL IV syringe 50 mg intravenous Given   11/10/2019 1029 cefTRIAXone 1 g in NS 10 mL IV syringe 1 g 1 g intravenous Given       Review of Systems Const:  Denies fever  Card:  Denies present chest pain Resp:  Denies shortness of breath and cough M-S: Left arm pain swelling and erythema Derm: Left arm pain, swelling and erythema       Initial Vitals [11/10/19 0802] BP Temp Pulse Heart Rate (cardiac monitor) Resp SpO2 Height Weight 122/72 97.6 °F (36.4 °C) 101 -- 18 95 % -- -- Physical Exam Appearance: Alert very pleasant female. Eyes: No conjunctival injection or drainage. No scleral icterus ENT: Pharynx: No posterior pharyngeal exudate. Moist mucous membranes.  No appreciable intraoral swelling.  Question while whether her lower lip is slowly more prominent, full Cardiac: Regular rate and rhythm. No murmur Pulmonary: Clear to auscultation. No wheezing or rales GI: Soft. No tenderness M-S: There is tenderness with palpation over the left arm over areas of erythema as well as soft tissue swelling.  Reaction appears to be localized to the humeral area and does extend just slightly below the elbow over the medial aspect of the patient's arm.  I do not appreciate swelling or erythema extending onto the shoulder or chest. Skin: With skin findings as noted above. Neurologic: Awake, alert, appropriate Labs: Ordered: Procedures ? CBC and Differential ? Basic Metabolic Panel ? C-Reactive Protein, High Sensitivity ? CBC and Differential   Labs Reviewed BASIC METABOLIC PANEL - Abnormal     Result Value Ref Range   Sodium 143  136 - 145 mmol/L   Potassium 3.8  3.5 - 5.1 mmol/L   Chloride 108 (*) 98 - 107 mmol/L   CO2 24  20 - 31 mmol/L   Anion Gap 14.8 (*) 6.0 - 14.0 mmol/L   Creatinine 0.99  0.55 - 1.02 mg/dL   Blood Urea Nitrogen 19.0  7.0 - 26.0 mg/dL   BUN/Creatinine Ratio 19.19  10.00 - 30.00 ratio   Calcium 9.2  8.4 - 10.2 mg/dL   Glucose 123 (*) 70 - 105 mg/dL   eGFR 58 (*) >=60 mL/min/1.73m(2)   eCrCl (Rx) - Adults 38.0  mL/min C-REACTIVE PROTEIN, HIGH SENSITIVITY - Abnormal   CRP, High Sensitivity 112.0 (*) 0.0 - 8.0 mg/L COMPLETE BLOOD COUNT AND DIFFERENTIAL - Abnormal   WBC Count, Corrected 7.9  4.5 - 11.0 10(3)/uL   RBC Count 4.41  4.00 - 5.20 10(6)/uL   Hemoglobin 12.7  12.0 - 16.0 g/dL   Hematocrit 37.4  33.0 - 51.0 %   MCV 84.8  80.0 - 100.0 fL   MCH 28.8  26.0 - 34.0 pg   MCHC 34.0  32.0 - 36.0 g/dL   RDW 13.3 (*) 11.5 - 13.0 %   Platelets 209  150 - 450 10(3)/uL   MPV 9.3  6.5 - 10.0 fL   % Neutrophils 67.4  35.0 - 77.0 %   % Lymphocytes 14.1 (*) 24.0 - 44.0 %   % Monocytes 17.4 (*) 3.0 - 6.0 %   % Eosinophils 0.3  0.0 - 3.0 %   % Basophils 0.3  0.0 - 1.0 %   % Immature Granulocytes 0.5  0.0 - 1.1 %   Abs Neutrophils 5.3  1.5 - 8.5 10(3)/uL   Abs Lymphocytes 1.1  1.1 - 5.0 10(3)/uL   Abs Monocytes 1.4 (*) 0.1 - 0.7 10(3)/uL   Abs Eosinophils 0.0  0.0 - 0.3 10(3)/uL   Abs Basophils 0.0  0.0 - 0.1 10(3)/uL   Abs Immature Granulocytes 0.04  0.00 - 0.14 10(3)/uL COMPLETE BLOOD COUNT AND DIFFERENTIAL   Narrative:    The following orders were created for panel order COMPLETE BLOOD COUNT AND DIFFERENTIAL. Procedure                               Abnormality         Status                    ---------                               -----------         ------                    COMPLETE BLOOD COUNT AND...[268893482]  Abnormal            Final result                Please view results for these tests on the individual orders.                                                        Course: Patient resents for evaluation of apparent reaction versus secondary infection after receiving a pneumonia vaccination.  It does appear symptoms started after receiving this injection although the exact timeline is not completely clear.  She does report some tingling around her lips and does have a slightly question of a prominent lip lower.  Differential includes an allergic reaction given these findings versus a cellulitis that subsequently developed after her injection versus a DVT of the upper extremity though likely is more of an allergic type reaction.   She was bolused with Solu-Medrol, Benadryl as well as ranitidine in the emergency department.  I did elect to cover her with antibiotic therapy for the potential for a cellulitis as she does have an elevation in her CRP today. Pt has no history of MRSA.  White blood cell count was normal however.  No fever documented today.   I did obtain an ultrasound of the patient's left upper extremity to rule out acute DVT formation although the patient is likely at low risk for this.  Us today is negative.  No notation of abscess formation or deeper infection.   Patient will be continued on Benadryl over-the-counter, prednisone and ranitidine.  I did elect to also place the patient on ongoing antibiotic therapy given the unclear nature of her symptoms today.  I do expect this patient's symptoms should improve over the next 24 hours.  Should patient develop a fever or additional symptoms including oral swelling, patient will seek prompt follow-up.  I did ask patient to seek follow-up nonetheless with her primary in approximate 24 to 48 hours.  She voices her understanding of this plan of care and ultimately is discharged home in the care of her husband.     From doctors visit on 11/12/19: HENT: No sore throat, rhinorrhea, sinus congestion, earaches. Eyes: No changes in vision, double or blurry vision. Cardiovascular: No chest pain or heart palpitations. Respiratory: No coughing, wheezing or shortness of breath. Gastrointestinal: No nausea, vomiting, diarrhea or constipation. No hematochezia. Genitourinary: No hematuria, dysuria or frequency. Musculoskeletal: No myalgias or arthralgias. Neurological: No dizziness, lightheadedness, or syncope. Skin: Swelling, erythema, and rash of left upper arm as per HPI. Heme: No bleeding or clotting tendencies. Psychiatric: No anxiety or depressive symptomsConstitutional: Oriented to person, place, and time. Appears well-developed and well-nourished. No distress.  HENT:  Head: Normocephalic.  Right Ear: Tympanic membrane, external ear and ear canal normal.  Left Ear: Tympanic membrane, external ear and ear canal normal.  Mouth/Throat: Uvula is midline, oropharynx is clear and moist and mucous membranes are normal. There is no posterior oropharyngeal erythema, no oropharyngeal exudate, or posterior oropharyngeal edema.  Nose: No rhinorrhea, no pain with palpation of frontal sinuses, no pain with palpation of maxillary sinuses. Eyes: Right eye exhibits no discharge. Left eye exhibits no discharge.  Neck: Normal range of motion. Neck supple. No cervical lymphadenopathy present.  Cardiovascular: Normal rate, regular rhythm and normal heart sounds. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No wheezes. No rales.  Abdominal: Soft. Bowel sounds are normal. No distension. There is no tenderness.  Skin: Left upper arm is no longer erythematous, and rash is resolved.  There is slight swelling which is in the process of resolving.  ROM is wnl.  CMS pink warm with good capillary refill.