Received Feb 26, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| VARZOS | ZOSTER (SHINGRIX) | GLAXOSMITHKLINE BIOLOGICALS | 2 | GA99K | IM / LA |
Patient presents with concern for reaction to her shingles vaccine. The patient got her second dose of shingles vaccine yesterday. She notes that yesterday evening development of headache, diffuse myalgias and bodyaches, nausea poor appetite. There has been no fever. There has been no cough congestion no infectious symptoms. The patient notes pain to her right ear as well as both TMJs. She notes pain essentially to her entire body. She has tried sumatriptan hand for the headache as well as ibuprofen. She was advised to come to the ICC for evaluation. Later in the discussion she also notes that she has had dysuria since this morning as well as dark-colored urine.
unknown
Cardiovascular Hypercholesterolemia Mitral valve disorder Other migraine without status migrainosus, not intractable Endocrine Hypothyroidism, unspecified type Neurologic Primary insomnia Genitourinary Kidney stones Recurrent UTI Menorrhagia Other LLQ pain
Atorvastatin 40mg QD, Levothyroxine 50mcg QD, Sumatriptan 50mg PRN, Zyrtec D 5-120 Q12, Famotidine 40mg BID,
Sulfa abx, Aspirin, Codeine, Latex
History of Present Illness 52-year-old female presents to ED with severe pain following her second COVID vaccine (Shingrix) administered yesterday at 3 PM. Around 8-9 PM, patient developed racing heart and nausea. She reports being unable to sleep all night. By 2-3 AM, she developed severe pain in her head, jaws, ear, neck, and shoulders bilaterally, worse on the injection side. Pain is rated 8-9/10 and has remained constant throughout the day. Patient reports minimal oral intake today except for 'a banana and a couple things', remaining mostly bed-bound due to pain. Patient initially presented to immediate care, where exam revealed clear ears with some fluid but no infection. Urinalysis at immediate care showed blood, raising concern for possible rhabdomyolysis. Has attempted treatment with 'couple doses of Advil' and two doses of sumatriptan without relief. Past Medical History Includes: Migraine headaches Mitral valve prolapse with murmur Lumbar spinal stenosis Medications Include: Sumatriptan PRN for migraines Ibuprofen PRN Social History Includes: Denies tobacco use Vital Signs: Temperature: 98.4F Heart rate: 111 Respiratory rate: 16 Blood pressure: 164/101 SpO2: 100% on room air Physical Exam: General: Patient is awake and alert HEENT: Pupils equal and reactive, TMs clear bilaterally, oropharynx normal, neck supple Cardiovascular: Tachycardic with regular rhythm, no murmur appreciated Respiratory: Clear bilateral breath sounds Musculoskeletal: Diffuse posterior cervical and thoracic tenderness Skin: Warm, dry, normal color Neuro: No focal deficits, neck flexion intact Abdomen: Soft, nontender Extremities: No peripheral edema or calf tenderness Review of previous records: Urgent care visit earlier today noted clear ears with some fluid, non-concerning Urinalysis positive for blood Medical Decision Making: Problem List: 1. Severe musculoskeletal pain post-vaccination 2. Possible rhabdomyolysis 3. Tachycardia 4. Hypertension Differential Diagnosis: 1. Vaccine reaction 2. Rhabdomyolysis 3. Myositis 4. Acute kidney injury 5. Migraine 6. Cervical strain ED Plan: 1. IV fluids 2. CK and comprehensive metabolic panel 3. Microscopic urinalysis 4. IV ketorolac for pain 5. Monitor vital signs Procedure Medication Dose Route sodium chloride 0.9% intravenous solution (Normal Saline Bolus) 1000 mL IV Bolus ketorolac (ketorolac inj) 15 mg IV Push Reexamination/Reevaluation I reviewed and interpreted labs, white count is 8.6, normal hemoglobin, normal renal function and acid-base balance. Urinalysis shows small amount of blood with 0-2 RBCs. No evidence of infection. CK total was 127, no indication for rhabdomyolysis. The blood in the urine does not likely represent any serious problem, though should be followed as outpatient. I do not have the results that prompted the patient to be sent here to determine if this is improved or similar. Discussed the limitations of the evaluation. Patient feels much better with fluid and Toradol. She is comfortable with discharge and outpatient follow-up. MB fraction is not back, in my opinion is not indicated so unclear why this was reflexively tested. I do not suspect any cardiac etiology. Advised patient to follow-up on this. Assessment/Plan 1. Myalgia 2. Vaccine reaction Discharge Instructions given to patient: With: Address: When: TESS CURNYN 52500 FIR RD GRANGER, IN 46530 (574) 271-0700 Business (1) Within 2 to 3 days Comments: We did not find any evidence of a dangerous metabolic process. I suspect your symptoms are related to the reaction of your immune system to the shingles vaccine. Make sure you stay hydrated and drink plenty of fluid. Take ibuprofen and acetaminophen to help with pain. I cannot be certain we are not missing anything or that your condition will not worsen. Follow-up with your PCP. Return for problems or concerns. VIS, Shingles - CDC Problem List/Past Medical History Ongoing Heart murmur History of UTI Hx of mitral valve prolapse Hx of thyroid disease Kidney stones Menorrhagia Historical No qualifying data Procedure/Surgical History Bladder hernia repair- umbilical Tonsillectomy uretheral sling uterine ablation Medications Inpatient No active inpatient medications Home atorvastatin 40 mg oral tablet, 40 mg= 1 tab(s), PO, hs calcium (as citrate)-vitamin D 500 mg-12.5 mcg (500 intl units)/5 g oral powder for reconstitution, See Instructions ketorolac 10 mg oral tablet, 10 mg= 1 tab(s), PO, QID, PRN levothyroxine, 50 mcg, daily Multiple Vitamins oral tablet, 1 tab(s), PO, daily Norco 5 mg-325 mg oral tablet, 1 tab(s), PO, q6h, PRN Pepcid 20 mg oral tablet, 20 mg= 1 tab(s), PO, once Zofran ODT 4 mg oral tablet, disintegrating, 4 mg= 1 tab(s), PO, q8h, PRN ZyrTEC-D, 1 tab(s), PO, BID, PRN Allergies Latex (rash) aspirin (upset stomach) codeine (upset stomach,Nausea) sulfADIAZINE (N&V) Social History *Tobacco Use: Never smoker., 10/05/2019 Alcohol Use: Does Not Use., 07/19/2021 Substance Abuse Use: Does Not Use., 07/19/2021 Family History Family history is negative Lab Results Past 24 Hour Labs: Event Name Event Result Date/Time WBC 8.6 x10(3)/mm3 01/21/25 18:10:00 RBC 5.13 x10(6)/mm3 01/21/25 18:10:00 Hemoglobin 14.2 g/dL 01/21/25 18:10:00 Hematocrit 41.9 % 01/21/25 18:10:00 MCV 81.7 fl 01/21/25 18:10:00 MCH 27.7 pg 01/21/25 18:10:00 MCHC 33.9 g/dL 01/21/25 18:10:00 Platelet 370 x10(3)/mm3 01/21/25 18:10:00 MPV 8.5 fl Low 01/21/25 18:10:00 RDW 11.8 % Low 01/21/25 18:10:00 RDW-SD 36.1 fl Low 01/21/25 18:10:00 Neutro Auto 69.7 % 01/21/25 18:10:00 Lymph Auto 19.5 % 01/21/25 18:10:00 Mono Auto 8.4 % 01/21/25 18:10:00 Eos Auto 1.9 % 01/21/25 18:10:00 Basophil Auto 0.5 % 01/21/25 18:10:00 Immature Granulocyte Auto 0 % Low 01/21/25 18:10:00 Abs Neutro 6 x10(3)/mm3 01/21/25 18:10:00 Abs Lymph 1.68 x10(3)/mm3 01/21/25 18:10:00 Abs Mono 0.72 x10(3)/mm3 01/21/25 18:10:00 Abs Eos 0.16 x10(3)/mm3 01/21/25 18:10:00 Abs Basophil 0.04 x10(3)/mm3 01/21/25 18:10:00 Immature Granulocyte Absolute <0.03 Low 01/21/25 18:10:00 Sodium 140 mmol/L 01/21/25 18:10:00 Potassium 3.7 mmol/L 01/21/25 18:10:00 Chloride 103 mmol/L 01/21/25 18:10:00 CO2 23 mmol/L 01/21/25 18:10:00 AGAP 14 01/21/25 18:10:00 BUN 10 mg/dL 01/21/25 18:10:00 Creatinine 0.76 mg/dL 01/21/25 18:10:00 eGFRcr 94 mL/min/1.73m2 01/21/25 18:10:00 Glucose 112 mg/dL High 01/21/25 18:10:00 Calcium 9.5 mg/dL 01/21/25 18:10:00 Lactic Acid 0.8 mmol/L 01/21/25 18:10:00 UA Color YELLOW 01/21/25 17:45:00 UA Bili NEGATIVE 01/21/25 17:45:00 UA Clarity CLEAR 01/21/25 17:45:00 UA Blood SMALL Abnormal 01/21/25 17:45:00 UA Glucose NEGATIVE 01/21/25 17:45:00 UA Ketones NEGATIVE 01/21/25 17:45:00 UA Leuk Est NEGATIVE 01/21/25 17:45:00 UA Nitrite NEGATIVE 01/21/25 17:45:00 UA pH 6.5 01/21/25 17:45:00 UA Protein NEGATIVE 01/21/25 17:45:00 UA Spec Grav <=1.005 Abnormal 01/21/25 17:45:00 UA Urobilinogen 0.2 01/21/25 17:45:00 UA WBC 0-5 01/21/25 17:45:00 UA RBC 0-2 01/21/25 17:45:00 UA Squam Epithelial None_Seen 01/21/25 17:45:00 UA Bacteria None_Seen 01/21/25 17:45:00 SARS-CoV-2 RT-PCR Not Detected 01/21/25 17:45:00 Influenza A by PCR Not Detected 01/21/25 17:45:00 Influenza B by PCR Not Detected 01/21/25 17:45:00 Ck Total 127 U/L 01/21/25 18:10:00