Age: 22.0
Sex: F
Vaccine: FLU3
Symptoms: Temperature intolerance, Tenderness, Transferrin decreased, Transferrin saturation, Vitamin B12 normal
Clinical narrative: Patient received IIV in her left upper arm around 0830, on 8 Nov 2016. Does not recall anything different about vaccine administration technique. Around 1800 on 8 Nov 2016 (day of vaccine receipt), patient noted a burning pain in her left hand, primarily in palm and fingers. Pain is intense (7-8/10) and constant; It worsens when the affected hand is near heat like when washing hands with hot water or when hand is in contact with laptop; pain has not changed in character over the past 15 hours. There is no numbness and tingling or weakness of extremity. No changes in the appearance of her hand. No history of trauma. Patient went to ER last p.m. (8 Nov 2016) and did not mention receipt of IIV earlier in the day. She was instructed to take BENADRYL to help her sleep, but no additional instruction and no diagnosis. On 9 Nov 2016, patient evaluated. Per PCM: 22 yo F presents to clinic with pain/numbness in her L and R hand and fingers for the past 2 days. SXs started the night after she had a flu shot and she believes that it may be an adverse reaction. Heat is the only thing that triggers the SXs--primarily located in palm and distal finger tips of all fingers except for thumb. She has taken TYLENOL with no improvement in SXs. Denies fever, chills, recent hand/neck trauma, HX of carpal tunnel, HX of reactions to flu vaccinations, neck pain. Does admit to HX of tendonitis in hands/wrist/forearms. EXAM: Musculoskeletal System: Hands: Right hand: Normal. No nodules. Hand was not tender on palpation. No limitation of motion was seen. No pain was elicited by motion. No weakness. Left Hand: Normal. No nodules. Hand was not tender on palpation. No limitation of motion was seen. No pain was elicited by motion. No weakness. Wrist: Right Wrist: Tenderness on palpation. Phalen's maneuver showed numbness/tingling in the median nerve distribution. Normal. No swelling. No nodules. No misalignment. Motion was normal. Wrist showed normal stability. Left Wrist: Tenderness on palpation 1st extension tendons bilat. Phalen's maneuver showed numbness/tingling in the median nerve distribution numbness in palm and distal fingertips bilat except thumb. Normal. No swelling. No nodules. No misalignment. Motion was normal. Wrist showed normal stability. Neurological: Oriented to time, place and person. Sensation: Sensory exam abnormalities were noted - Decreased sensation to light touch in left C5-6 distro vs right. Motor (Strength): Strength of the upper extremities was normal. No weakness of the right wrist was observed. No weakness of the left wrist was observed. Balance: Normal. Gait and Stance: Normal. Skin: Showed no ecchymosis. Temperature was normal. No skin lesions. Nails normal. ASSESSMENT/PLAN: Hyperesthesia: Vitals WNL. Neurovascularly intact in bilateral UE. Pain and numbness do not follow a specific nerve pattern--more of stocking and glove. Basic labs ordered. Will begin trial with gabapentin--titrate up to 900 mg daily--advised of possible SE. F/U in 1 month if not improved-consider NCV at that time. RX: Gabapentin 300 mg, MOBIC 15 mg. On 21 Nov 2016, patient's pain significantly improved, but not completely resolved.