4/25/18 The shoulder where I had the second of the pneumonia shots yesterday is red and hot. Also, the glands (?) under that arm are sore. 4/26/18 My arm feels better but is still somewhat hot. The redness seems to be moving down the arm. 4/26/18 Physician Visit Patient is here today for a reaction at her PNEUMOVAX 23 site. She had a PNEUMOVAX booster placed at her visit on 4/24/2018. The following day she had some redness and warmth in the lateral upper arm. She came in to the office for me to take a look. At that time I felt it was just likely an injection site reaction. She was asked to use ZYRTEC 10 mg every morning and BENADRYL 25 mg daily at bedtime and come back today if her symptoms were worse or if the redness or swelling progressed. She called today stating that the arm was less full feeling but she did think that the redness had extended down her arm and she reported her husband was concerned. Therefore I brought them back in the office today just to take another look. Here, she does have a distinct delineation mark about halfway down her upper arm with an area of redness warmth and induration that is nearly square in shape above it. Superior to this, there is a more diffuse area near the injection site where she does have just a more pink colored skin. None of the areas are very tender to touch. Due to progression of symptoms and worsening erythema and swelling, I do think it is prudent to cover her with antibiotics in case this is a mild cellulitis. She will start KEFLEX 500 mg twice a day. She will try to elevate the arm while she is laying down. We did delineate the area of erythema with a line today. She will let me know if the redness crosses this line. We'll plan on checking on her tomorrow. 4/27/18 Physician Visit Patient presents today for subsequent evaluation of injection site reaction to PNEUMOVAX. She had a PNEUMOVAX booster placed in left upper arm at her visit on 4/24/18. The next day, patient complained of redness and warmth in the lateral upper arm and was instructed to take ZYRTEC and BENADRYL. Patient presented yesterday (two days post-vaccination) with worsening redness. Dr. prescribed KEFLEX for possible mild cellulitis. A line was also drawn delineating the area of erythema and the patient was instructed to notify us if the erythema crossed that line. Patient returns today stating that her arm has improved overall, but the redness has slightly crossed the line drawn yesterday. She states it feels warm, but is not painful. Patient says the erythema around her shoulder has improved and slowly moved down her arm. She denies fever, chills, chest pain, shortness of breath, dysphagia. She complains of malaise. She is eating and drinking normally. Continue antibiotic therapy. Resume ZYRTEC and BENADRYL for the next few days. Explained that fatigue and malaise are likely due to the vaccine and should resolve in a few more days. Also explained that it is not unusual for erythema to slowly spread down the arm due to gravity in a dependent area. Patient expressed understanding and agreed to maintain previously prescribed management. Patient will monitor erythema and let us know if redness spreads back up the arm toward the shoulder. She will notify us if she develops fever, chills, or shortness of breath.