Age: 52.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, Crying, Injection site induration, Injection site pain, Injection site swelling
Clinical narrative: patient presents reporting received 2nd dose of Pfizer yesterday in her left deltoid no concerns at the time of the injection or immediately afterward around 7pm her left wrist started hurting and moved up to left arm she is in such severe pain, she cannot move it and has been up all night crying took some ?otc pain med without relief reports pain from fingertips to shoulder, worse in wrist/forearm pain is 10/10 reports she is currently on NO prescription medication lives alone (with 2 dogs) see problem list, including h/o mononeuritis multiplex denies noted swelling/redness/increased skin temp of LUE no discoloration of LUE denies numbness/paresthesias denies true weakness; having severe pain with any movement of LUE ROS Constitutional: Constitutional: no fever or significant weight gain.  Cardiovascular: Cardiovascular: no chest pain or shortness of breath when walking.  Respiratory: Respiratory: no cough, wheezing, or shortness of breath (breathing is currently at baseline).  Gastrointestinal: Gastrointestinal: no vomiting, diarrhea, or abdominal pain.  Genitourinary: Genitourinary: no difficulty urinating.  Musculoskeletal: Musculoskeletal: no swelling in the extremities.  Integumentary: Skin: no jaundice or rashes.  Neurologic: Neurologic: no dizziness or headaches.  Additionally reports: since yesterday: Physical Exam Patient is a 52-year-old female.  Constitutional: Level of Distress: severe distress; frequently tearful due to pain. Ambulation: limited ambulation (due to pain).  Psychiatric: Insight: good judgement. Mental Status: active and alert. Orientation: to time, place, and person. Memory: recent memory normal and remote memory normal.  Head: Head: normocephalic and atraumatic.  Eyes: Lids and Conjunctivae: non-injected. Pupils: PERRLA.  Neck: Neck: supple and no masses. Lymph Nodes: no cervical LAD. Thyroid: no enlargement or nodules and non-tender.  Lungs: Respiratory effort: no dyspnea. Auscultation: rhonchi, inspiratory wheezing, and expiratory wheezing and good air movement; (patient reports stable for her).  Cardiovascular: Heart Auscultation: RRR and no murmurs. Neck vessels: no carotid bruits. Pulses including femoral / pedal: normal pedal pulses.  Abdomen: Bowel Sounds: normal. Inspection and Palpation: no tenderness, guarding, masses, or rebound tenderness and soft and non-distended.  Musculoskeletal:: Motor Strength and Tone: normal tone. Extremities: no cyanosis or edema.  Neurologic: Gait and Station: normal gait. Cranial Nerves: grossly intact.  Skin: Inspection and palpation: no rash and good turgor.  LUE exam: + mild swelling/induration over left deltoid at site if IM injection with no redness/increased skin temp or fluctuance over injection site mod/severe tenderness left deltiod over injection site  visual exam of LUE with no gross abnormalities no swelling/redness/increased skin temp of entire no discoloration or induration of remainder LUE severe tenderness to palpation of upper LUE; patient could not tolerate palpation of remainder of LUE AROM decreased throughout LUE due to pain, but no obvious limitation + hyperesthesia to light touch LUE Assessment / Plan 1. Adverse reaction to COVID-19 mRNA vaccine - patient in SEVERE PAIN ?possible Parsonage Turner syndrome patient declines going to ER discussed with Dr. who agrees with plan below will report t VAERS discussed with patient will need to go to ER if no relief with below or if ANY new symptoms (can talk to on-call provider over the weekend prn questions) f/u in 3 days if only tolerably better f/u with me 1 week T50.B95A: Adverse effect of other viral vaccines, initial encounter M79.2: Neuralgia and neuritis, unspecified ketorolac 60 mg/2 mL intramuscular syringe - Inject 60 mg every day by intramuscular route.  Solu-Medrol (PF) 125 mg/2 mL solution for injection - Take 125 mg by injection route.  prednisone 20 mg tablet - Take 3 tablet(s) every day by oral route for 5 days.   acetaminophen 300 mg-codeine 30 mg tablet - Take 1 tablet(s) every 6 hours by oral route for 7 days.  Discussion Notes pt verbalizes understanding and agrees with plan