Received Oct 15, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE) | SANOFI PASTEUR | 1 | U8881BA | IM / RA |
| TDAP | TDAP (ADACEL) | SANOFI PASTEUR | 1 | U8620BA | IM / LA |
Patient received vaccines on 9/30/25. Patient stated that she did not have any pain for 3 days, states that she woke up in the middle of the night and her left arm was in pain. States that she knows that the Tdap is painful and just figured that is what is was from. States by 10/14/25 the pain had not subsided so she decided to come in and have it checked out. She was trying to document through CDC but she needed information regarding the vaccine to do so. Patient has had left shoulder pain since before 2023. Had x-rays done on 2/20/23 for left shoulder pain. And also had already had right shoulder surgery. Hx of recurring acute left shoulder pain.
No
Borderline Personality Disorder, Anxiety/Depression, Acute pain of left shoulder
Cetirizine, Flexeril, Ibuprofen, Meloxicam, Promethazine, Rizatriptan, Valacyclovir, Creon, inhalers
Buspirone
Provider ordered another X-ray of left shoulder and ordered PT for patient.