Received Oct 28, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE) | SANOFI PASTEUR | UNK | UT8820AA | IM / RA |
Per Provider APRN Right arm pain: - Patient reports pain following influenza vaccination on 10/07/2025 - Symptoms began 48 hours post-vaccination: redness, swelling, warmth, deep pain - Pain worsens with movement - Tenderness over lateral aspect of elbow and humeral head - Pain present when making a fist with right hand - X-ray of right shoulder to be conducted today to rule out other causes - Rest, apply ice and heat to sore areas - Ibuprofen 800 mg every 8 hours with food - Tylenol 1000 mg every 4-6 hours for baseline pain management - Flexeril 10 mg every 8 hours as needed for muscle spasms - Avoid driving, alcohol consumption, and operating heavy machinery while on Flexeril - Consider physical therapy or cortisone injection if no improvement 2. Numbness and tingling of the right hand: - Numbness and tingling in right hand, especially index and middle fingers and thumb - Symptoms worsen with use - Monitor for changes and report new symptoms - Further evaluation and potential referral to specialist if symptoms persist 3. History of influenza vaccination: - Received influenza vaccination on 10/07/2025 in right arm - Symptoms of pain, redness, swelling, warmth began 48 hours post-vaccination - Suspecting possible SIRVA or shoulder injury related to vaccine administration Follow-up: - Patient advised to follow up in the next couple of weeks to report progress
No acute illness documented per clinic vaccination screening form completed or EHR
Hypertension Pulmonary nodule/lesion, solitary Obstructive sleep apnea Morbid obesity with BMI of 45.0-49.9, adult (HCC) Type 2 diabetes, HbA1c goal < 7% (HCC) Mixed hyperlipidemia Thyroid nodule Former smoker Polycythemia secondary to smoking Fatty liver History of diverticulosis Dermatochalasis of right upper eyelid Dermatochalasis of left upper eyelid Palmoplantar pustulosis Alopecia Rheumatoid arthritis involving multiple sites with positive rheumatoid factor (HCC) Status post cholecystectomy Status post breast reduction Restless leg syndrome Migraine without aura and without status migraineurs, not intractable S/P complete hysterectomy Periodic limb movement disorder Lupus erythematosus overlap syndrome (HCC) Grade A3 albuminuria
amitriptyline (ELAVIL) 10 mg tablet carbidopa-levodopa (SINEMET) 25-100 mg per tablet folic acid (FOLVITE) 1 mg tablet hydroxychloroquine (PLAQUENIL) 200 mg tablet JARDIANCE 10 mg tablet lisinopriL (PRINIVIL,ZESTRIL) 10 mg tablet metFORMIN
Allergies Cat Dander Adverse Reactions/Drug Intolerances: Augmentin [Amoxicillin-pot Clavulanate], Pravastatin
10/27/25-XR SHOULDER COMPLETE MIN 2 VIEWS RIGHT