Received Aug 4, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE) | SANOFI PASTEUR | 1 | UT8437DA | IM / RA |
Reported Symptoms: 10003239: ARTHRALGIA; 10047862:WEAKNES; 10047865: WEAKNESS GENERALIZED; Narrative: Patient is a 89-year-old man with a history of AAA, CAD, CHF, inguinal hernia presenting for leg pain and weakness. Accompanied by his daughter who helps provide significant history. State that last week he received an influenza vaccination. Beginning that night he had significant pain to his right leg. Described as occasional calf pain predominantly upper leg pain radiating to his groin. No injury. Described longstanding weakness. No fevers or chills. They are concerned about a possible blood clot. Using Tylenol and ibuprofen but patient having trouble sleeping as ibuprofen wears off. Patient was daughter also notes that she discontinued his Lasix several months ago as she felt it was making him lightheaded and he had more bilateral lower extremity edema. On initial exam he was comfortable appearing and hemodynamically normal. Lack of focal neuro symptoms reassuring against CVA. Labs reassuring against significant infection, occult blood loss or metabolic derangement. Description of the symptoms not consistent with symptomatic AAA. X-rays reassuring against fracture dislocation, do show significant arthritis in both of the knee joint. Ultrasound reassuring against DVT. Overall favor arthritic pain as the cause of his symptoms. Do question whether lower extremity edema is contributing as well and advised them to resume his Lasix and follow up with the primary provider. They were in agreement with this. Advised patient to attempt use of naproxen over Advil for extended coverage
Temperature 09/23/24 36.7C Pulse Rate 09/23/24 73 Resp rate 09/23/24 18 Blood Pressure 09/23/24 133/78 SpO2 09/23/24 98% Pain Score 5/10 - Moderate Pain