Age: 17.0
Sex: F
Vaccine: MENB
Symptoms: Injection site swelling, Myalgia, Nausea, Neck pain, Paraesthesia
Clinical narrative: Office Visit, 9/11/2017. Pediatrics Vaccination reaction, initial encounter +4 more. Dx Allergic reaction. Reason for visit. Progress Notes. Chief Complaint Patient presents with ? Allergic reaction, TRUMENBA, dizziness, limb numbness, hives, nausea, headache, weak, muscle pain. History of Present Illness Patient presents today with: HPI Comments: Patient is here with mother for a sick visit. Allergic reaction. This is a new problem. Episode onset: since 3 days ago. The problem is unchanged. Associated with: got TRUMENBA vaccine first dose 3 days ago. The exposure occurred at home. Associated symptoms include abdominal pain and diarrhea. Pertinent negatives include no chest pain, coughing, itching or rash. (Nausea and dizziness, swelling redness and blotchiness of left arm at the injection site, numbness and tingling of lower legs on the day of vaccine). Past treatments include ibuprofen and acetaminophen. The treatment provided mild relief. Review of Systems. Constitutional: Negative for fever. Respiratory: Negative for cough. Cardiovascular: Negative for chest pain. Gastrointestinal: Positive for abdominal pain and diarrhea. Genitourinary: Positive for frequency. Musculoskeletal: Positive for myalgias (both flanks hurt) and neck pain. Negative for back pain, joint swelling and neck stiffness. Skin: Negative for itching and rash. Neurological: Positive for dizziness, lightheadedness and headaches (frontal headaches and pain in back of neck). All other systems reviewed and are negative. Historical Data Patient's history, medications, and allergies were reviewed and updated as appropriate. Physical Exam BP 100/68 | Pulse 62 | Temp 98.8 °F (37.1 °C) (Oral)  | Wt 115 lb (52.2 kg) | LMP 08/29/2017 | BMI 20.37 kg/m2. Physical Exam: Constitutional: She is oriented to person, place, and time. Vital signs are normal. She appears well-developed and well-nourished. HENT: Head: Normocephalic and atraumatic. Right Ear: Tympanic membrane, external ear and ear canal normal. Left Ear: Tympanic membrane, external ear and ear canal normal. Nose: Nose normal. Mouth/Throat: Uvula is midline, oropharynx is clear and moist and mucous membranes are normal. Eyes: Conjunctivae, EOM and lids are normal. Pupils are equal, round, and reactive to light. Neck: Trachea normal, normal range of motion and phonation normal. Neck supple. No thyromegaly present. Cardiovascular: Normal rate, regular rhythm, S1 normal, S2 normal, normal heart sounds, intact distal pulses and normal pulses. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. Abdominal: Soft. Normal appearance and bowel sounds are normal. She exhibits no mass. There is no hepatosplenomegaly. There is no tenderness. There is no rebound. Musculoskeletal: Normal range of motion. Arms: Lymphadenopathy: She has no cervical adenopathy. She has no axillary adenopathy. Neurological: She is alert and oriented to person, place, and time. She has normal strength and normal reflexes. No cranial nerve deficit or sensory deficit. Skin: Skin is warm. No rash noted. Psychiatric: She has a normal mood and affect. Her speech is normal and behavior is normal. Thought content normal. Cognition and memory are normal. Nursing note and vitals reviewed. Assessment/Plan: Patient was seen today for allergic reaction. Diagnoses and all orders for this visit: Vaccination reaction, initial encounter. Dizziness - ZOFRAN, PO TAB 4 mg; Give 1-2 Tabs by mouth 3 times daily as needed for nausea. TRUMENBA Vaccination reaction, initial encounter. Numbness and tingling of both legs. Muscle pain - ADVIL, PO TAB 200 mg; Give 3 Tabs by mouth every 6 hours as needed for pain or fever. WATCH FOR NEXT 5-7 DAYS FOR RESOLUTION OF SYMPTOMS. IF WORSE NECK PAIN/RIGIDITY OR FEVER OR HEADACHES NEED TO BE REEVALUATED. Mother verbalizes understanding and agrees with the treatment plan. Mom was given adequate opportunity to ask questions and were answered to her satisfaction.  REPORT FILED TO VAERS WEBSITE.