Received Jul 16, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| PNC21 | PNEUMO (CAPVAXIVE) | MERCK & CO. INC. | 1 | Y019158 | IM / RA |
Patient received Capvaxive vaccine on 6/23/2025 in her right deltoid, was monitored for 15 minutes afterward and tolerated immunization administration well. She states she developed mild arm pain that evening, which has persisted since that time, for approximately 23 days. She has taken ibuprofen with some relief. She reports the pain is localized to the muscle, and hurts when raising her right arm off a table. She denies any signs of infection, including redness, swelling, warmth, or fever. Advised patient to try alternating acetaminophen and ibuprofen, apply warm or cold compresses as needed, offered patient appointment to be seen today or tomorrow and she is unable to come in. Discussed other evaluation opportunities with patient, and she plans to go to a walk in orthopedics clinic this week for evaluation.
none
? Insomnia ? Hypothyroidism ? Diabetes mellitus type 1, uncomplicated (HCC) ? Depression ? Cerumen impaction ? Change in voice ? Chronic throat clearing ? Diabetes mellitus (HCC) ? Esophageal dysphagia ? Globus sensation ? Hallux hammertoe, left ? Skin ulcer of left great toe, limited to breakdown of skin (HCC) ? Carpal tunnel syndrome ? Bilateral posterior capsular opacification ? Bilateral pseudophakia ? Disturbance of skin sensation ? Dry eyes, bilateral ? Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral (HCC) ? Lesion of ulnar nerve ? Vitreous hemorrhage (HCC) ? Vitamin D deficiency ? Proteinuria ? Polyneuropathy due to type 1 diabetes mellitus (HCC) ? Mixed hyperlipidemia ? Hereditary and idiopathic peripheral neuropathy ? Hyperglycemia due to type 1 diabetes mellitus (HCC) ? Essential hypertension ? Ataxia
atorvastatin (LIPITOR) 10 mg tablet Take 10 mg by mouth daily ? cyanocobalamin (VITAMIN B-12) 100 mcg tablet Take 100 mcg by mouth 1 (one) time each day ? Dexcom G7 Receiver misc ? Dexcom G7 Sensor device ? FLUoxetine (
No known allergies
None.