Received Sep 29, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| UNK | VACCINE NOT SPECIFIED (NO BRAND NAME) | UNKNOWN MANUFACTURER | 1 | ZOO3579 | IM / LA |
The patient received the pneumococcal vaccination on Wednesday, September 3, 2025. She appears to have mounted a robust immunologic response with fever and malaise on the same day. Despite these symptoms, she went to her physically demanding job, which involves manual labor and sweating. Patient seen in the office on 9/8/2025 developed clinical features concerning for cellulitis localized to the left upper extremity. The erythema has been progressively spreading to the anterior, posterior, and medial aspects of the arm. The arm is warm to touch, with diffuse erythema. She denies fever, chills, or changes in mental status. On examination, the vaccination site demonstrates a circular ecchymosis without surrounding erythema or peripheral edema, making injection-site reaction less likely. The presentation is more consistent with cellulitis rather than a local vaccine reaction. Given the extent and progression of findings, I have decided to initiate broad-spectrum antibiotic therapy with Bactrim DS to provide MRSA coverage.
Seasonal allergic rhinitis due to polen
Irritable bowel syndrome, hyperthyroidism, mixed hyperlipidemia, obstructive sleep apnea, pre-diabetes,
cetirizine HCl (capsule) cetirizine 10 mg Take 1 capsule by mouth daily. famotidine (tablet) PEPCID 20 MG Take 1 tablet (20 mg total) by mouth 2 (two) times a day as needed (allergies). levothyroxine sodium (tablet) SYNTHROID, LEVOTHROID 75
Penicillins
No labs ordered. Broad spectrum prescribed to provide MRSA coverage.
fever, malaise, circular ecchymosis