Received Apr 22, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 1 | 8080473 | IM / RA |
Per Dr.'s office visit note from 4/21/25: Patient received a vaccination for COVID-19 (Spikevax 12) on 9/17/2024 in his right shoulder during one of our vaccine clinics. Patient states that it was the single most painful immunization he has ever received. He states that ever since then, he has decreased range of motion of his right shoulder," has a classic frozen right shoulder". In fact, patient does demonstrate decreased range of motion of the right shoulder although no clicking or locking is felt. He is he is able to feed himself with his right hand. There is no numbness or tingling. Patient reports no prior injury to the right shoulder. I will have to do some investigating into this vaccine and his complaint. Also, if I cannot find any direct link or any solution, we will go ahead and order PT and proceed from there to an MRI and Ortho consult as needed
No other illnesses
Back pain, neuropathic pain bilateral lower extremities
Lunesta 1 mg q HS, lorazepam 0.5 mg q HS, oxycodone 10 mg q HS PRN, Maxalt 10 mg PRN
bee venom
Patient is being referred to physical therapy with potential for MRI and ortho consult if needed.