Age: 54.0
Sex: M
Vaccine: COVID19
Symptoms: Back pain, Hypoaesthesia, Loss of personal independence in daily activities, Muscular weakness, Nausea
Clinical narrative: Situation/Background:   Patient with interpreter  calling for right arm pain and numbness.   Received incoming call from patient who responded, "Started on the night of when I had the vaccine; persisted this whole time; it's not getting better; even my back starts to hurt now."   No HA "but I feel nauseated";  no vomiting, no diarrhea, "maybe a little bit constipated". No chest pain, no SOB. No swelling, no redness but there is "numbness; right arm, it's very weak and I have no strength"; overlying skin appears normal; "aching pain and numb".    Two vaccines (COVID and flu) were administered on 03/26/2024 at office visit.  "My hand/fingers are ok; can use hand; my shoulder down to my elbow" is numb; patient is ambidextrous; "I normally use my left but can also use right".   Pain and numbness "never stopped; sometime I would use some oil to help to release the pain but once evaporated, the pain returns". "I tried painkillers (ibuprofen) but it didn't work". "Can't sleep because of the numbness; it's very hard to handle;  have to take sleeping pills (melatonin?)" to promote sleep.    Patient declined appt on Saturday afternoon; no appts available Friday/tomorrow.  Advised ED evaluation today given that onset of condition was 9 days ago without any improvement.  Patient verbalized understanding but stated that he would like to wait and if pain/numbness become intolerable, then he would to go ED.    Assessment:   Reason for Disposition ? Weakness (i.e., loss of strength) in hand or fingers  (Exception: Not truly weak; hand feels weak because of pain.)  Answer Assessment - Initial Assessment Questions 1. ONSET: "When did the pain start?"     On 03/26/2024 after COVID vaccine administration 2. LOCATION: "Where is the pain located?"     Right arm; there is also numbness from shoulder to elbow 3. PAIN: "How bad is the pain?" (Scale 1-10; or mild, moderate, severe)   - MILD (1-3): Doesn't interfere with normal activities.   - MODERATE (4-7): Interferes with normal activities (e.g., work or school) or awakens from sleep.   - SEVERE (8-10): Excruciating pain, unable to do any normal activities, unable to hold a cup of water.     Moderate; interferes with sleep  4. WORK OR EXERCISE: "Has there been any recent work or exercise that involved this part of the body?"     Recent vaccine administration at right arm 5. CAUSE: "What do you think is causing the arm pain?"     COVID vaccine 6. OTHER SYMPTOMS: "Do you have any other symptoms?" (e.g., neck pain, swelling, rash, fever, numbness, weakness)     No redness/swelling; no HA, no CP, no SOB 7. PREGNANCY: "Is there any chance you are pregnant?" "When was your last menstrual period?"     NA  Protocols used: Arm Pain-A-AH Recommendation:   Disposition/Plan:    Protocol Recommends: Pt to present to ED. Per nursing judgment.   An appropriate appt is not available. ED recommended. ED dispo declined. RN reviewed risk of delayed treatment.   Pt verbalizes understanding and declines advice.   RN reviewed care advice instructions, when to call back and when to seek emergency medical attention. Caller educated on Centralized Nurse Triage contact information and availability.    Patient had no medications administered during this visit.   No orders of the defined types were placed in this encounter.