Received Feb 25, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 6 | 3043153 | IM / RA |
PATIENT EXPERIENCE IMMEDIATE SWELLING REDNESS AND WARMTH AT INJECTION SITE. OVER THE MONTHS FOLLOWING VACCINATION SHE EXPERIENCED NODULAR AREAS OF SWELLING FROM THE RIGHT SHOULDER TO THE RIGHT HAND. THESE ARE NOT RESOLVING AS OF THIS REPORT DATE. SHE IS ALSO EXPERIENCING PAIN IN THE RIGHT ARM , WRIST AND HAND .
Circulatory Paroxysmal atrial fibrillation Hypertension associated with diabetes Digestive Vitamin D deficiency Genitourinary CKD (chronic kidney disease) stage 2, GFR 60-89 ml/min Musculoskeletal Arthritis of both knees Endocrine/Metabolic Mixed diabetic hyperlipidemia associated with type 2 diabetes mellitus Insulin dependent type 2 diabetes mellitus Hypertriglyceridemia Other Postmenopausal state Encounter to establish care with new doctor Encounter for monitoring ACE-inhibitor therapy Deferred condition on axis I Preventative health care Osteoporosis screening Need for zoster vaccination Need for Tdap vaccination Need for pneumococcal vaccination Need for influenza vaccination Encounter for annual wellness visit (AWV) in patient Asymptomatic postmenopausal status Post-vaccination reaction, initial encounter Overweight with body mass index (BMI) of 28 to 28.9 in adult Encounter for monitoring digoxin therapy
Circulatory Paroxysmal atrial fibrillation Hypertension associated with diabetes Digestive Vitamin D deficiency Genitourinary CKD (chronic kidney disease) stage 2, GFR 60-89 ml/min Musculoskeletal Arthritis of both knees Endocrine/Metabolic Mixed diabetic hyperlipidemia associated with type 2 diabetes mellitus Insulin dependent type 2 diabetes mellitus Hypertriglyceridemia Other Postmenopausal state Encounter to establish care with new doctor Encounter for monitoring ACE-inhibitor therapy Deferred condition on axis I Preventative health care Osteoporosis screening Need for zoster vaccination Need for Tdap vaccination Need for pneumococcal vaccination Need for influenza vaccination Encounter for annual wellness visit (AWV) in patient Asymptomatic postmenopausal status Post-vaccination reaction, initial encounter Overweight with body mass index (BMI) of 28 to 28.9 in adult Encounter for monitoring digoxin therapy
? Current Medications ? History Comments Name Order Details Adh Start End Authorized By Outpatient Medications Accu-Chek Guide test strips USE AS DIRECTED TO TEST BLOOD SUGARS THREE TIMES DA
Severity Reactions Comments Heparin Analogues High welts Eemt [estrogens-methyltestosterone] Not Specified Heparin Not Specified Unknown Jardiance [empagliflozin] Not Specified Other (See Comments) Sores in her mouth Potassium Not Specified Amlodipine Besylate Low Swelling behind eyes Penicillins Low Rash Sulfa (sulfonamide Antibiotics) Low
NA