Received Jul 9, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| TDAP | TDAP (BOOSTRIX) | GLAXOSMITHKLINE BIOLOGICALS | 2 | L5229 | IM |
Patient was seen at the travel clinic 3/19/25 where tdap immunization was administered Left middle deltoid. Patient saw Urgent Care 4/10/25 where voltaren gel was prescribed for injection site pain. Patient also called into injection administering clinic 4/10/25 reporting soreness and pain in her arm from the tdap injection. I had connected with travel provider 4/11/25 and patient got a response/update 4/11/25 from provider care team, reporting to have her see Primary Care Provider for symptoms. Patient did get an Ortho referral placed 4/10/25. Patient got in with family practice 4/14/25 to get her symptoms checked out. 4/14/25 visit with family practice encounter has photo of the bullae with erythema that formed at injection site. Dermatology was consulted at this time and antibiotics prescribed. Culture of bullae collected at 4/15/25 office visit with family practice. E-consult to ID submitted 4/15/25 by family practice. ID responded 4/15/25 to e consult with antibiotic recommendations. Patient was called 4/17/25 and updated that culture was negative. 6/13/25 visit with family practice, xray and MR L shoulder ordered. Xray completed 6/13/25 and MRI completed 6/27/25. Patient was updated that MRI results "subdeltoid bursitis, but otherwise is normal" on 6/30/25. Patient was seen at family practice 6/27/25, "Follow-up Shoulder pain extending to neck from tdap vaccine. Hot/cold packs and lidocaine patches help. Keeps pt up at night." Photo of injection site in 6/27/25 family practice visit note. Flexeril was ordered as needed at this encounter as well. Patient to see orthopedics.
none
Backache Dyspepsia Disorder of bursae and tendons in shoulder region Hypothyroidism (HRC) Insomnia HTN (hypertension) (HRC) Knee pain SI (sacroiliac) joint dysfunction (HRC) Increased prolactin level Vitamin D deficiency (HRC) Elevated serum creatinine Medial meniscus tear Screening for malignant neoplasm of cervix Costochondritis Complex tear of medial meniscus of left knee as current injury Pre-diabetes Malignant carcinoid tumor of jejunum (HRC) Metastasis to peritoneum (HRC) Omental metastasis (HRC) Duodenal perforation (HRC) Primary malignant neuroendocrine tumor of ileum (HRC) Dyslipidemia (HRC) Frequent PVCs Premature atrial contractions Family history of dyslipidemia Familial combined hyperlipidemia Asymmetry of optic nerve of right eye Bilateral radiating leg pain Radicular pain of both lower extremities Lumbar stenosis with neurogenic claudication Lumbar radicular pain Stage 3a chronic kidney disease (HRC) Herpes simplex disease Primary hyperparathyroidism (HRC)
norvasc, zyrtec, vitamin d3, gabapentin, synthroid, cozaar, pravastatin,
Atorvastatin Not Specified Other, see comments Elevated CK level. Augmentin [amoxicillin-pot Clavulanate] Not Specified Gastrointestinal Severe diarrhea Crestor [rosuvastatin] Not Specified Other, see comments Elevated ck Ibuprofen