Received Mar 26, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| TDAP | TDAP (BOOSTRIX) | GLAXOSMITHKLINE BIOLOGICALS | N/A | 3ZH27 | IM / LA |
Office Visit Note 3/18/25 - Pain began after vaccine administration. Pain is throbbing and affects sleep. She has been sleeping in recliner to try and reduce pain. She has used heat and ice. Patiently, she has significantly reduced range of motion of the left shoulder. She has continued to work, but does not have full use of left arm. Significantly reduced range of motion of the left shoulder. Only able to actively abduct to approximately 30 degrees. Passive range of motion is slightly better, although patient has significant pain with this. Can use NSAIDs, but must stop 2 weeks prior to upcoming breast surgery. Can try Flexeril at night. Also recommend that she begin physical therapy as soon as possible. Physical Therapy Note 03/24/2025 - ASSESSMENT Patient presents to physical therapy evaluation with primary c/o L shoulder pain. The results of the objective tests and measures show decreased L shoulder ROM, decreased L shoulder strength, positive rotator cuff testing. Functional deficits include but are not limited to Reaching overhead, reaching across body, lifting. Signs and symptoms are consistent with diagnosis of Acute pain of left shoulder (M25.512). Pt and PT discussed evaluation findings, pathology, POC and HEP. Pt voiced understanding and performs HEP correctly without reported pain. Skilled Physical Therapy is medically necessary to address the above impairments and reach functional goals.
Invasive ductal carcinoma right breast
Hypothyroidism. Migraine, Rheumatoid Arthritis,
Biotin oral, Cholecalciferol 2000 UT oral, Multi Vitamin oral
No known Allergies