Received May 27, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| PNC20 | PNEUMO (PREVNAR20) | PFIZER\WYETH | N/A | LN4930 | IM / LA |
Patient presented at clinic for triage of allergic reaction on 5/27/2025. HISTORY: - Patient reported she received the pneumococcal vaccine on Thursday 5/22/2025, which she believes is the cause of her allergic reaction. - On Saturday night, she developed severe itching on her left arm where the vaccine was administered. Her left arm also became hard, turned red, and developed bumps which were suspected to be hives. - Patient reported severe itching has persisted since Saturday night. She is unable to wear long sleeve shirts due to this. She took expired Benadryl this morning and has been applying Gold Bond anti-itch lotion which did not help. ASSESSMENT: - Left arm visualized. Moderate erythema > 3 inches visualized. No swelling, hives, open wounds, or warmth. Patient denied fevers, chills, shortness of breath, chest pain, nausea, vomiting. NEXT STEPS: Given allergic reaction, consulted with provider of day. She advised patient to stop taking Benadryl due to potential for drowsiness and instead take cetirizine (Zyrtec) twice daily (once in the morning, once at night) and apply hydrocortisone ointment or cream twice daily (once in the morning, once at night). Patient was also advised to return to the clinic if symptoms worsen despite recommended home treatment with OTC medications. Patient confirmed understanding and agreed to plan, no further questions or concerns at this time.
Rib fracture diagnosed on 5/13/2025
Osteoporosis, scoliosis, shoulder impingement syndrome, PPD positive, trigger finger of right thumb
Biotin, calcium, vitamin D, and Tylenol as needed for pain.
Aspirin