Age: 40.0
Sex: F
Vaccine: FLU3, IPV, TYP
Symptoms: Tongue disorder
Clinical narrative: This is a 40-year-old female who went down to the travel nurse and received several immunizations on Wednesday afternoon, March 12. She had a previous hepatitis A vaccine on 02/12/2008. On 03/12/2008, she had an influenza which looks as though it was put into the IM deltoid of the right arm. She had a polio IPV on 03/12/2008, subcu in the left upper arm, and a typhoid IM in the deltoid on the left. Where she is having her pain and discomfort it was shortly after receiving the immunization, she points to the lower of 2 immunizations that appears to be more along the posterior aspect of the arm and it is about a quarter in size. It is more at the triceps area or the inferior and lateral aspect of the deltoid where the polio was given. There was an immunization given IM and that looks like it would be a little more superior and we suspect that would be the typhoid. Regardless, the patient has broken out in a rash that is maculopapular throughout her entire body, face, on the top of her head.  She first noticed the rash on Thursday am when she woke up. (The vaccines were given Wednesday afternoon.)  She has them in her mouth. She does feel that she has had a slightly thick-sounding tongue. She has had some facial edema and she also feels that her throat is tight.  The facial edema and throat tightness were first noticed on Friday am.  Again, her rash is about her upper abdomen, her chest, her upper back, her arms, her face, her neck, and now into the groin area, a little bit less so on the legs. She did have some dizziness on Thursday and she felt this was maybe secondary to this and did not have any throat symptoms until today. OBJECTIVE: Temperature is 98.4. Blood pressure is 102/68. Weight is 247.6. On exam, she is a pleasant, cooperative lady with a rash about her face with also some swelling, some thick-sounding voice probably secondary to histamine release. On examination, the ears are without erythema. The nose is patent, no drainage. Tongue in the midline. Tongue does appear to be somewhat thick. She does have spots on the inside of her mouth at the oropharynx that are similar to those on her skin. No exudates at the throat. No sore throat is otherwise noted. The neck is supple, anterior adenopathy 1+. The lungs are clear throughout all lung fields. No wheezing, rales, or rhonchi noted. She is not having difficulty swallowing. Rash is maculopapular. It is pretty much peppered throughout the face, neck, and upper extremities. Examination of the injection site reveals an erythematous area that appears to be more like a hive. I can see the outline of the Band-Aid. I can also see the outline of the gauze central area of the Band-Aid as well. It is warm to touch. The other injection site appears to be more in the upper portion of the arm closer to the humeral head and I do not see any irritation there. The right arm does not reveal any irritation or reaction to the injection. Abdomen is soft, nontender without hepatosplenomegaly.   Plan:  We will get her started on some Benadryl at night and I did give her some samples of Claritin and Xyzal, which is the new antihistamine on a once a day basis that she could try if she prefers. Cool showers, symptomatic care. Aveeno anti-itch lotion would be recommended. We did not feel that a cortisone injection was appropriate at this time, although she may need further evaluation if she is not showing adequate clearing.