Received May 12, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUAD) | SEQIRUS, INC. | 1 | 388484 | IM / LA |
Persistent lingering left deltoid injection site pain since the immunization. Pain increases after work once he settles at home. Heating pad and ibuprofen is not helping. PredniSONE (Deltasone) 20 MG tablet; Take 2 Tablets by mouth one time a day for 5 days. Physical Therapy referral.
Left Rotator cuff tear, Arthritis of left acromioclavicular joint
Hypertension
atorvaSTATin (Lipitor) 40 MG tablet, furosemide (Lasix) 20 MG tablet, omeprazole (PriLOSEC) 20 MG delayed-release capsule
no known allergies
X-ray of the shoulder demonstrates arthritic change as well as bone spur development which appears to be consistent with longstanding chronic rotator cuff tendinopathy. Follow-up with orthopedics. MRI- Complete full-thickness tear of the supraspinatus and infraspinatus tendon with retraction of 3 to 4 cm.