Received Oct 9, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUBLOK) | SANOFI PASTEUR | 1 | U8832AA | IM / LA |
Patient had vaccine 09/23/25. She was seen at the office on 09/29/2025 by Dr.- "Patient is a 56 year old female who presents with neck stiffness and rash following a flu vaccine. She received a flu vaccine at pharmacy on Tuesday. That night, she developed a low-grade fever and a headache localized to the left side of her head. She has a history of headaches but no previous migraines. The following day, she experienced neck stiffness and pain, making it difficult to turn her head. The symptoms persisted into Thursday, with the headache becoming more severe and extending between her shoulder blades, causing significant discomfort. She described the pain as feeling like 'someone needed to punch me right there just to relieve the pressure.' She managed her symptoms with alternating doses of Tylenol and Advil from Tuesday until Friday morning. On Friday, she noticed a discoloration from underneath her breast around the left side, which was not itchy and was discovered after a shower. Her fever resolved over the last couple of days. No chills or sweats, although she experiences menopausal symptoms, which include sweating. No photophobia. She has been informed of elevated blood pressure, which she states has never been high before, and she is concerned about the implications for her job. Assessment & Plan Myositis, neck and back muscle inflammation, and acute neck pain following influenza vaccination Acute myositis and muscle inflammation in the neck and back following influenza vaccination, with significant torticollis and muscle pain. Symptoms likely due to inflammatory response to the vaccine or reactivation from previous COVID vaccinations. Symptoms include severe neck stiffness and pain radiating between shoulder blades. - Order blood tests to assess inflammation markers - Prescribe Flexeril for muscle relaxation - Prescribe dexamethasone to reduce inflammation - Advise against taking Flexeril before flying Headache following influenza vaccination Headache localized to the left side of the head following influenza vaccination, persistent over several days. Likely related to the inflammatory response from the vaccine. - Prescribe Fioricet for headache management Allergic rash following influenza vaccination Development of a non-itchy rash on the left side of the body following influenza vaccination, likely an allergic reaction to the vaccine. Rash is not causing significant discomfort. - Prescribe dexamethasone to address the rash Elevated blood pressure secondary to acute illness Elevated blood pressure likely secondary to stress and discomfort from acute illness and inflammation. Not a chronic issue as blood pressure has been normal in the past. Expected to resolve as inflammation decreases. - Reassess blood pressure on follow-up visit tests ordered CBC, CMP< Creatine kinase, and lipid panel." She then went to ER on 09/29/25 for worsening symptoms. "Patient 56-year-old female with PMH as above here for evaluation of chills as well as neck pain and headaches that the patient has been experiencing over the past 6 days since receiving her influenza vaccination. She saw her primary care physician yesterday and was diagnosed with a reaction to the influenza vaccine. She was given a prescription for prednisone but did not take it yet. She was also given a prescription for Flexeril which did not help her with the pain. Physical exam as above. Labs reviewed are grossly unremarkable and reassuring. She is noted to have a slight elevation in her ESR and CRP levels which represents inflammation. White blood cell count is normal. COVID-19 testing was negative. Urinalysis was questionable for urinary tract infection. When the patient was questioned, she did not has been a urinary tract infection symptoms. Urine culture has been performed by the lab and we will contact the patient back if the results are positive for a bacteria that will require antibiotics for treatment. CT angiogram of the head and neck performed showed no evidence of any acute intracranial/vascular pathology. The patient has been reassured by the negative workup. She felt better with the medications that she received here. I has been discontinued her Flexeril and has been given her a prescription for tizanidine to help her with the neck pain. She does not have any signs or symptoms to suggest that she has meningitis/encephalitis at this time. The patient feels comfortable being discharged home. She has been instructed take the prednisolone that she was prescribed. Patient will follow up with PCP and return if any worsening symptoms. Amenable to this plan and appreciative of care delivered. Amount and/or Complexity of Data Reviewed: Labs: ordered and details documented in ED Course Radiology: ordered, independent interpretation and details documented in ED Course Details: I have independently interpreted the patient's CT angiogram of the head and neck and see no evidence of any acute intracranial/vascular pathology. ECG/medicine tests: ordered, independent interpretation and details documented in ED Course Details: I have independently interpreted the patient's EKG and see no evidence acute ischemic changes. Risk Medication(s): OTC drugs and prescription drug management Escalation of care including admission / observation considered: Admission considered but there is little to suggest that the patient requires admission to the hospital at this time. Therefore, deferred. Then seen by Dr. on 10/01/25- Active problems addressed during this encounter: 1. Other myositis of left shoulder (Primary) 2. Postimmunization reaction, initial encounter Improving. No evidence of phlebitis. Monitoring clinically. " Then symptoms worsened again- on 10/06/25 "Good Morning Dr., I had been feeling much better after my reaction to the flu vaccine and all seemed to be going fine but on Thursday, I began having a dull headache on the left side of my head again with random "electrical shocks" to my ear drum and down the back of my head. Not excruciating, but annoying and a constant dull ache just below my rib cage on the left side of my back. I was supposed to fly on Saturday but I did a telecom appointment and Dr. advised I go back on steroids and start with the muscle relaxers and Zyrtec again, so I called out for my flight. He prescribed me a course of Prednisone and I have been taking all the meds he recommended. Is this something I should be concerned about, or did I just need more meds to counter the effects of the reaction? Thank You, Patient" Seen on 10/09/25 by Dr. for follow-up. "Follow Up (Pt was feeling much better and all seemed to be going fine but on Thursday (10/02), she began having a dull headache on the L side of her head again with random "electrical shocks" to L ear drum and down the back of head. Not excruciating, but annoying and a constant dull ache just below rib cage on the left side of back.She has a rash, face discoloration, weakness in left arm, fatigue, dry mouth, & voice (raspy). Done muscle relaxer. Never took oxy. Only taking prednisone taper. No supplements. )" "Active problems addressed during this encounter: 1. Acute vasculitis (Primary). Postimmunization reaction, subsequent encounter. Other myositis of left shoulder. Allergic dermatitis. Left ptosis and trigeminal neuralgia? Other intractable trigeminal autonomic cephalgia (TAC) Mononeuritis multiplex and (dermato)myositis in postvaccination vasculitis are a concern. GBS-like symptoms or MFS are theoretical possibilities but are unlikely. Will follow on steroids and order work-up. Will consider repeat imaging if further progression happens. - BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC Routine - COMPREHENSIVE METABOLIC PANEL Routine - SEDIMENTATION RATE RBC AUTOMATED Routine - C-REACTIVE PROTEIN Routine - CREATINE KINASE TOTAL Routine - COMPLEMENT TOTAL HEMOLYTIC Routine - IMMUNOGLOBULIN PANEL (IGG, IGA, IGM), SERUM Routine - predniSONE (DELTASONE) 10 mg tablet; Take 4 Tablets by mouth once daily for 3 days, THEN 2 Tablets once daily for 14 days, THEN 1.5 Tablets once daily for 7 days, THEN - anti-ganglioside Gq1b antibodies - REFERENCE TEST Blood Blood Routine"
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latex and penicillin
As Above. Seen on 09/29/2025 Dr. ER on 09/29/2025, Dr. 10/01/2025 and 10/09/2025