Received Oct 15, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA MNEXSPIKE)) | MODERNA | 1 | 3052736 | IM / LA |
Patient is a 78 year old male here for Reaction to Immunization (Ov for "Reaction to Covid vaccine 9/30" c/o L/arm agonizing pain- today still c/o L/shoulder joint pain, c/o RUQ pain since vaccine "my liver hurts") Vaccine was Moderna; all of his other COVID vaccines were Pfizer Worse the day after with constant pain in L arm and torso; unable to move arm at all Moved out of the torso and into the arm only the next day but he could not move his arm at all By Sat(Day 4) , he could lift his arm only waist high Since Day 5 his arm gradually returned to full movement Armpit itched terribly but has resolved He has also been having pain in his RUQ since Day #2 off and on; not related to food
None
CAD, elevated PSA, Hyperlipidemia, OSA, Nonthrombocytopenic Purpura, Psoriasis, History of Pulmonary embolism, Basal Cell Cancer, HTN, SVT, Former smoker
Lisinopril 40 mg a day, Amlodipine 5 mg a day, Fenofibrate 134 mg a day, Warfarin 5 mg a day, Rosuvastatin 10 mg a day, Vit B12 1000mcg a day, Eye Health Areds-2
Penicillin, Sulfa
CMP, Lipase, CK Isoenzymes- results as within normal limits