Age: 25.0
Sex: F
Vaccine: MMR
Symptoms: Injection site erythema, Injection site pain, Pallor, Skin warm
Clinical narrative: Patient presents to clinic at approximately 1745 on 6/25/09 for MMR immunization - enrolled in medical assistant program at local school, cannot find old shot record, requests MMR per school requirement for proof of immunization.  PMHx:  Cervical cancer (surgically excised 2003, no recurrence), asthma (stable), environmental allergies ("many" per patient).  Previous smoker, quit one year ago.  Medications:  Claritin-D 24 hour once daily, loestrin 24 Fe, Nasacort, Singulair, Advair Diskus 100/50 one puff once daily, Cipro 500 mg twice daily x 10 days (has one dose of cipro left to take for sinus infection, patient reports feeling well and completely recovered from sinus infection).  Patient had TB skin test placed 3 days prior, site incidentally noted to be nonreactive/negative.  Medication allergies: PCN (anaphylaxis, nausea, vomiting).  Patient denies any live vaccines given within the last 30 days, denies any contraindications to vaccination (no allergy to gelatin or neomycin, no prior history of adverse reaction to MMR vaccination in past, not pregnant or planning on becoming pregnant in the next 4 weeks, no alterations in immune status, no immunosuppressive therapy, no blood products/immune globulin in the last 11 months, no history of thrombocytopenia, no latex allergy, not moderately or severely ill). Patient noted to be somewhat anxious. Patient reviews VIS sheet (3/13/2008) for MMR, directed to ask vaccine administrator any questions she might have (none), vaccine and general consents completed, signed and dated.  Temperature orally is 98.0 F.  Vaccine manufacturer:  Merck, lot# 0356x.  Vaccine reconstituted per facility and manufacturer guidelines.  Vaccine administered left upper arm, postereolateral, subcutaneously; no blood aspirated prior to injection.  Patient reports significant pain initially during and for one or two minutes after injection at injection site, then reports a throbbing sensation, left forearm, midway between elbow and wrist - "where I had my old TB skin test".  Patient reports redness at that site (vaccine administrator unable to appreciate any change in skin color, no induration or warmth, no change in pain to palpation).  Fingers/hand warm, dry, pink bilaterally, color/sensation/motion bilaterally equal, palpable radial pulse left.  Patient also reports dizziness "like when I had morphine" - blood pressure 138/90, heart rate 91, respirations 16.  Patient denies any difficulty breathing, no shortness of breath, wheezing, chest tightness or dyspnea.  Breathing is easy, nonlabored, no retractions, no wheezing appreciated. Skin color at baseline was pale, no change in skin color noted throughout, skin warm and dry throughout.  No changes noted in level of consciousness.  Patient continues to be somewhat anxious.  Vital sign recheck 10 minutes later - 120/90, heart rate 70, respiratory rate 16.  Continues to deny difficulty breathing, continues to report dizziness.  Vaccine administrator contacts medical director, updates regarding patient situation, and she concurs with referral to nearest ER for evaluation, transport by grandmother.  Patient and grandmother escorted to vehicle, given written directions to ER, directed to proceed directly to ER. Vaccine administrator contacted patient 6/26/09 at 0830 at home phone number - patient reports having a "breathing reaction" at Hospital, was treated with an albuterol nebulizer treatment with good relief. She indicates that the ER staff felt her anxiety contributed to her reaction.  She denies any current arm pain, but does report "a red bump below my old TB skin test site, it's still there, it doesn't hurt or throb, isn't swollen, it's just red".  She denies any current breathing difficulty.  Vaccine administrator directed her to contact her PCP today for follow-up, directed her to consult with PCP regarding future vaccinations.  Patient directed to call 911 or seek care at an ER is she experiences any further shortness of breath, chest tightness, dizziness, rash, or pain - she verbalizes understanding and agreement.