Received Mar 20, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUCELVAX) | SEQIRUS, INC. | UNK | Aw3227A | IM / RA |
Patient was seen in office on 10/21/2024. He received an influenza vaccine in right deltoid. Patient's pharmacy also administered Shingrix and RSV vaccine the same day. Patient followed up in office on 12/17/2024 with complaints of right upper extremity pain and swelling. Diagnosed with hematoma. Patient suffered with pain of right upper extremity due to hematoma X many months resulting in multiple Drs office trips, and ED visit, and MRI of right shoulder. MRI of right shoulder revealed advanced arthritic changes of the AC joint and glenohumeral joint with large joint effusion. There is complete tear of the supraspinatus and infraspinatus tendon compatible with superior rotator cuff tear. Tendonitis of the subscapularis and coracohumeral narrowing. Patient seen ortho on 3/4/25. Patient states that he was told that the hematoma caused from the vaccine has aggravated an old injury in his right shoulder and now he may suffer with chronic LROM and pain in right shoulder.
None
Hyperlipidemia, ED, HTN, T2DM, history of DVT, history of PE, vitamin D deficiency
rosuvastatin, sildenafil, lisinopril, asa, lantus, lispro, jardiance, xarelto,
Demerol
MRI, ED visit, Multiple Dr. appointments