Reporte zur Charge UT7096JA

Symptomtext

Pt received Fluzone injection on 12/18/202. Pt reported limited ROM at Left Arm and took OTC and Ibuprofen, reported to after hours Triage. On 12/21/2020, pt talked to Triage Nurse and reported increased sharp pain when trying to move her arm on Saturday and that she used heat/ice and ibuprofen. Pt reported on 12/21/2020 that sharp pain continues when she tries to lift her arm and that it was dull when she is not using her arm. She stated that over the weekend that she was awakened by sharp pain at her arm but denied redness or swelling at injection site. Pt stated that injection was done high on the shoulder and patient stated that she believes shot was given to high and sent in picture of where bandaid was placed. Dr. consulted on 12/21/2020 and 5 days worth of prednisone 20 mg sent in for patient on 12/21/2020 and told to follow up with office if issues continue. Pt messaged in on 12/30/2020 and stated that she only took one of the five prednisone, stating she was afraid that it would keep her up all night. Pt then advised to take 2 - 20 mg prednisone per day and Dr. advised patient to follow up with any more issues. Pt messaged in on 1/5/2021 stating that she is 60% better but continuing to have pain and discomfort with movement. Dr. continues to monitor and Dr. made referral to ortho specialist.