Age: 62.0
Sex: F
Vaccine: MMR
Symptoms: Arthralgia, Back pain, Condition aggravated, Erythema, Headache
Clinical narrative: Subjective: HPI: Patient presents to clinic today, 2/27/19 for evaluation. Patient received SQ MMR vaccine in right tricep muscle in right upper arm at clinic on 2/11/19 and noticed no reaction after administration, including no redness, swelling or pain at injection site. But 6 days later, patient noticed redness of the skin on her anterior chest and cheeks and blood shot eyes on Sun.7 am 2/17/19. Then patient reports she had onset of HA, achy fingers, wrists and low back on 2/18/19 and then 2/19/19 awoke having trouble getting out of bed due to severe back pain with forward flexion. Patient has hx of chronic non-industrial low back pain diagnosed with spondylosis and anterior lithiasis in Dec. 2018 by PMD and prior LBP with int. bilateral feet numbness but felt LBP flared to a higher degree of pain and decreased ROM on 2/19/19. Patient usually takes Celebrex qd per PMD. Patient called PMD on 2/19/19 (phone appnt) and PMD said she wanted to follow-up on non-industrial LBP and order an L-spine MRI-- to schedule in a few weeks and felt symptoms may be side effects to MMR vaccine on 2/11/19. Patient not scheduled to work until 2/21/19 & 2/22/19 and called in sick those two days as still had HA. Patient states flare of LBP any skin redness or hand/wrist jt pain and HA totally resolved by Sat. 2/23/19 and have been resolved ever since. Worked 2/25/19 & 2/26/19 without difficulty. PMH: Chronic: low vit D, singles x 2, asthma, Hashimotos thyroiditis, int. mild pain in ant. R shdr, chronic LBP due to lumbar ant. grade 1 spondylithiasis & spondylosis, hypertension; gained 30 lbs in last 6 mths. Sx: none Rx: levothyroxine, Celebrex, Lisinopril, Advir bid, Albuterol q 4 hrs prn Allergy: Penicillin, Sulfa (hives) PSH: married, 5 grown children, non-smoker, Etoh: rare; Commute: 6 miles Occ Hx: ED RN x 30 years Physical Exam: Vitals: T: 98.8  BP: 140/68  HR: 73/min Eyes: conjunctiva clear, no discharge, no lesions, able to read 9 font w/o difficulty, PERLA. Skin: ruddy underlying complexion on cheeks and anterior chest, no rash, lesions or swelling noted. Neck: no noted deformity, bruising or swelling; FROM w/o pain. Head: normocephalic, NTTP over frontal sinuses or posterior occiput. R upper arm: no palpable soreness, lesion or bruising. Back: no noted deformity, bruising or swelling.  NTTP over T-spine & L-spine. NTTP lumbar musculature. FROM w/o pain. Sit SLR 90 degrees: negative bilaterally.  H/T walk WNL. [EE states back to usual baseline -- needs to stop and stretch forward if walks > 5 miles uphill] Hands/wrists: no deformity, bruising or swelling. FROM w/o pain. Grip strength WNL bilaterally. Neuro: Strength, sensory & DTRs WNL bil UE & LE. Assessment: Possible reaction on 2/17/19 to 2/11/19 MMR vaccine and all reaction symptoms fully resolved as of 2/23/19. Plan: Follow-up with PMD for underlying pre-existing personal medical conditions. Discussed case with Dr. clinic Medical Director. EH requested EE bring in note from PMD to document not to get MMR #2 vaccine. Discussed clinic will report her symptoms through VAERS, National Vaccine Injury Compensation program, and provide patient with VAERS contact # & information. No clinic follow-up indicated. NP