Age: 66.0
Sex: F
Vaccine: PPV, TTOX
Symptoms: Haemoglobin normal, Inflammation, Injection site erythema, Injection site induration, Injection site pain
Clinical narrative: From the physician Urgent Care note on 1/1/10- This 66 y/o FEMALE presents with - c/o immunization site pain on bilateral deltoids. Had pneumococcal on Rt and Tetanus on Lt. Rt deltoid is tender to touch 4/10, but no inflammation, hardness or swelling noted. Lt site has a 1-inch slightly reddened circle w/1 cm area that is hard to touch, tender, has been keeping vet awake tonight. She applied lanocaine lotion on it earlier and took TYLENOL yesterday for the pain, but nothing recently. Here to check as brother sleep and hasn't had this reaction before. Extremities- 1 areas of light pink injection b/l deltoids 1 cm area that is mildly firm but not circumscribed fluctuant mass nor heat, its mildly tender, strength intact with grip, normal limb muscle bulk UEs. From the physician Urgent Care note 1/3/10- she was seen here 2 days ago with an apparent inflammatory reaction to tetanus vaccine. She has been using NSAID's a local care, but still has pain and swelling of the left arm and wrist. Pain is from this shoulder down to the wrist. There is some stiffness noted. She has no chills or fever and no other complaints. The right arm is fine. Plan-start prednisone, 40mg po now and in AM, 20mg po daily x3 and 10mg po daily x3. From Domiciliary physician note 1/4/10- LABS-BMP, CBC, PT/INR, ESR have been unremarkable. Complement C3/C4 panel was sent out and is pending. From nursing note 1/4/1- A. Today the injection site on the left deltoid is slightly red, there is about a 2cm swelling noted at the area that is quite tender to the touch. Pr states her left wrist was swollen also, and both are getting better with the steroids. From Domiciliary physician note 1/8/10- Patient presents with chief complaint of urine smelling funny and looking darker. From Domiciliary physician note 1/11/10- Patient presents with chief complaint of allergic reaction to CIPRO. Says last night she began to itch and to have throat swelling. She chose NOT to go to UC facility, but decided to self treat with diphenhydramine- 3 doses 100mg po each, approx 4 hours apart. Reports my throat felt like it was swelling, my skin got red and began itching. No concurrent symptoms other than mild itch. Note her multiple allergies, all self reported below. From Domiciliary physician note 1/28/10- Patient was placed on a low-dose steroid taper and symptoms resolved without sequelae. Medication list from H&P 12/30/09- 1) Acetaminophen, 325mg to take two tablets by mouth active three times a day for pain (do not exceed 12 tablets per day), 2) Capsaicin 0.075% cream apply small amount topically active three times a day for joint pain. 3) Cholecalciferol (vit D3) 1,000Unit tab take one active tablet by mouth daily fro vitamin D. 4) Cyclobenzaprine HCL 10MG tab take one tablet by mouth active tree times a day as needed for muscle pain. 5) Flunisolide 0,025% 200D nasal inh spray - spray 2 puffs active in each nostril twice a day fro nasal allergies. 6) Levothyroxine NA (SYNTHROID) 0.125MG tab take one active tablet by mouth once a day before a meal (take alone on an empty stomach) for thyroid replacement. 7) Lidocaine 5% oint apply liberal amount topically active twice a day as needed for pain relief. 8) Pill splitter use as directed to split tablets active. 9) Psyllium oral PWD take 2 teaspoonfuls by mouth once active every day for constipation (mix in 8OZ of juice or water). 10) Quetiapine fumarate 100mG tab take one-half tablet by active mouth every morning and take one-half tablet at noon and take tree tablets at bedtime. 11) Vitamin B Complex with Vit. C take 1 caplet by mouth active daily for vitamin replacement. Prednisone - Dose: 21.25 - Units: MG - Freq: every day - Route PO.