Age: 47.0
Sex: F
Vaccine: HEPAB
Symptoms: Burning sensation, Erythema, Injected limb mobility decreased, Injection site discharge, Injection site erythema
Clinical narrative: Pt called Health Dept. on 2/7/24 with complaints of pain and limited ROM in right arm,  Recommended that pt return to the Health Dept for assessment and discussion of pt's complaints.  Visually noted localized swelling and redness at injection site to right arm.  Aarea of redness was 28mmx20mm.  Upon palpation, area of induration noted surrounding the immediate area of redness, as well as swelling exteding out twice the size of the noted read area.  Right deltoid was warm to the touch.  Pts oral temperature ws 98.1.  Injection site noted to be with recommednded are of injection.  During discussion pt stated "she noticed discomfort at injection areas shed was leaving the HD/ checking out and pain was noted by tme she arrived home(per patient, roughly 25min)  Pain continued and pt tollk 200mg of ibuprofen around 7:15 pm on 2/6/24 and iced area for at least 20min.  Pt stated that she believes the ice helped as the current area of swelling noted at the HD on 2/7/24 was smaller that what she noticed on 2/6/24 at her home.  Pt stated that are m was "heavy" and was painful to move upon waking up, but pain slightly decreased once she started moving her arm.   Pt also noted burning sensation down her arm, as well as pressure to the injection site/induration area noted on assessment.  Pt described the pain as a 6/10 and buring sensation as a 7/10.   Recommended that  pt continue to take ibuprofen to help with inflammation and ice the area.  Recommended continuing to move arm, enev if in passive movement with aid of left arm. Recommended to see PCP if symptoms do not improve within 48 hrs. of injection.    Further education on vaccines was provided to patient. IF patient - if pt starts to have any breathing issues or swelling of lips or difficulty breathing, then she needs to seek immediate emergent care.  Informed pt that reaction  to vaccine can occur with in the 1 week of vaccines and swelling and redness at injection site can be expected   The vaccine was given by a nurse with another nurse present in the room on 26/24.   Two nurses were present during the  assessment, discussion, recommedations and education with this patient. Pt to be called for follow up verbal assessment.on 2/8/24  Pt called on 2/8/24 in the morning to update on current symptoms.  Pt stated that starting last night (2/7/24) she started to have swelling, redness, and bumps on the chin and neck areas.  L side from pictures.  Pt stated that she also has 3 small nodules/"dots" behinde her ears, but was unable to take picures. Due to the new symptoms, pt stated that she took Zyrtec ( no Benadryl)  As of the morning of 2/8/24, pt still had the swelling,redness, and bumps pt aslso stated that arm is now itchy and the indureation area has not gotten better. Pt was asked if she had taken any Benadryl - pt stated  she had not taken benadryl due to benadryl amking her sleepy.  During conversation with patient, reviewed Vaccine screening checklist from 2/6/24 and verified she had no previous reactions to vaccines - pt stated she had no previous reactions to vaccine.  after phone call with patient, discussed pt's symptoms with ( nurse manager)  due to the arise of the newsympotoms that have progressed to her neck/chin, advisedment from nursing manager was for patient to go to the ED.   Returned phone call to patient after discussing case with nurse manager and advised pt to go to the ED for evaluation.  Pt asked if it was necessary to go to the ED ( could she go to urgent care instead and it was reitereated to pt that it is advisedmenet to go to the ED for her current symptoms.  Pt stated that she need to touch base with spouse.  repeated Follow up calls have been made, left voice mail, to calls have been returnded.  Follow up call placed 2/14/24 at 1:05 with no response.