Age: 68.0
Sex: F
Vaccine: PPV
Symptoms: Dysphagia, Erythema, Injection site erythema, Injection site pain, Injection site pruritus
Clinical narrative: Patient presented to ED w/ redness, hives, and itching to injection site approx. 10hrs post PPSV23 administration. Pt reported mild trouble swallowing. Treated w/ dexamethasone 8mg PO, Benadryl 50mg PO, and ketorolac 15mg IM. Discharged w/ hydroxyzine 10mg QID PRN itching, prednisone 20mg daily x3 days, tramadol 50mg Q12H PRN pain, and instructions to start ABX (Bactrim DS 800/160mg BID x5 days) if fever or redness to arm worsens.     CC:  Pneumococcal polysaccharide vaccine this am in the rt deltoid.  Pt has redness, hives, itchiing.  tender to touch below the injection site.  Airway patent, no tongue swelling.  States she is having mild trouble swallowing, no SOB and none noted.  HPI: 68 yo fm with recent vaccine from pneumonia polysaccharide. pt reports had prior vaccine from similar last year - (they have updated the valences). pt reports onset of increased redness and pain with swelling to arm where vaccine was given over the past 24 hrs. no known reaction to this vaccine in past. pt denies URI congestion or difficulty breathing. pt denies cough/congestion. pt is awake and alert.  A/P:  pt with extensive local reaction to arm -- do not think that this is infection at this time -- will treat as local reaction and cover with steroids and anti-inflammatories. pt stable for d/c home.  Medication Reconciliation    New  hydrOXYzine (hydrOXYzine hydrochloride 10 mg oral tablet)1 tabs Oral (given by mouth) 4 times a day as needed itching. Refills: 0.  predniSONE (predniSONE 20 mg oral tablet)1 tabs Oral (given by mouth) every day for 3 Days. Refills: 0.  sulfamethoxazole-trimethoprim (Bactrim DS 800 mg-160 mg oral tablet)1 tabs Oral (given by mouth) 2 times a day for 5 Days. start this if has fever/redness to arm that gets worse.. Refills: 0.  traMADol (Ultram 50 mg oral tablet)1 tabs Oral (given by mouth) every 12 hours as needed pain. Refills: 0.   Unchanged  alendronate (Fosamax 70 mg oral tablet)1 tabs Oral (given by mouth) every week. with 6 to 8 ounces plain water, at least 30 minutes before first food, beverage, or medication of the day. Refills: 3.  atorvastatin (atorvastatin 40 mg oral tablet)1 tabs Oral (given by mouth) every day at bedtime. Refills: 3.  cholecalciferol (cholecalciferol 25 mcg (1000 intl units) oral tablet)2 tabs Oral (given by mouth) every day. Refills: 3.  fluticasone nasal (Flonase 50 mcg/inh nasal spray)2 Sprays Nostril-Both (into the nose) every day. in each nostril. Refills: 11.  lidocaine topical (Lidoderm 5% topical film)1 patch(es) Topical (on the skin) every day. Leave on for up to 12 hours within a 24 hour period (12 hours on, 12 hours off). Refills: 3.  ocular lubricant (carboxymethylcellulose 1% gel eye drops)  polyethylene glycol 3350 (MiraLax oral powder for reconstitution)Dissolve 1 cap in 6-8 ounces of water or juice and drink PO twice a day until having soft stool then decrease to daily for constipation. Refills: 3.  sertraline (sertraline 100 mg oral tablet)1.5 tabs Oral (given by mouth) every day. Refills: 3.  ROS: REVIEW OF SYSTEMS: (Bolds for positive)  GENERAL: No fevers, excessive fatigue, falls  HENT: No rhinorrhea, ear pulling  RESPIRATORY: No difficulty breathing, wheezing, cough  ABDOMINAL: No vomiting, constipation, diarrhea, melena, hematochezia, hematemesis  GU: No decreased urine output, abnormal color or smell, hematuria  MSK: No new joint swelling, edema  NEUROLOGIC: No weakness, abnormal behavior, abnormal movements, loss of consciousness  SKIN: has rash- R arm.  Vitals & Measurements  T: 37.2  °C (Oral)  HR: 65(Peripheral)  RR: 16  BP: 101/52  SpO2: 95%  WT: 60.00 kg(Dosing)  WT: 60 kg(Measured)   PE: GENERAL:  Well nourished, well developed. Appears stated age. No acute distress.  HEAD:  Atraumatic. Normocephalic.   EYES:  No conjunctival injection. EOMI.  ENT:  Moist mucosa. No nasal discharge. External ears normal.  NECK: No tracheal deviation.  CARDIOVASCULAR: Well perfused. Regular rate and rhythm.  PULMONARY:  No respiratory distress. Airway patent. CTAB.  ABDOMINAL: Soft, non-tender, and non-distended.  EXTREMITIES:  No peripheral edema. No gross deformities noted.  SKIN:  R arm red and warm and swelling. normal sensation to hand - normal movement. pt has likely local hyperimmune response since just has prior vaccine to same arm.  NEUROLOGICAL:  Alert, awake, and appropriate. CN II-XII grossly intact. Sensation and motor function grossly intact. Normal speech.    PSYCHIATRIC: Appropriate mood and affect.