Received Nov 6, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE) | SANOFI PASTEUR | 1 | 406990 | IM / LA |
Pt received the flu shot on 9/15/2025 on left deltoid. pt has no complaints after receiving vaccine. VIS form was provided to pt. Infomed pt he may have pain, tenderness at the injection site and he can take tylenol/ibuprofen to the area. If there is swelling it should subside. If swelling develops and does not resolve, pt is to go to ER or f/u. Pt comes into clinic today 11/6/25 stating that since the flu shot, he has intermittent "shocking" sensation of left thumb that radiates to forearm with driving or sitting . When asked initially if he had pain of left shoulder , he denied. Later he changes the history and said he has pain from left shoulder down ,NO numbness, NROM of left shoulder and thumb with all movements. No swelling of left thumb or shoulder. MA informed clinician pt has not been taking his psychiatric meds. Pt is a poor historian . He is difficult to understand due to thick accent, Explained to pt next plan of care is to refer to neurology for nerve conduction test. Pt declined. "I do not have the money." I want to file a claim." "I will take this to court." It was recommended to pt that imaging such as MRI can be done prior to neuro referral , pt declined and he left the clinic. pt mentioned at one point that there was bleeding at injection site. Pt was not clear whether it was after the injection or later. He would no answer question directly. He did not quanitfy the amount of bleeding. "I want to file a claim". This may be with reference with what is written in the VIS form for flu. pt never came in earlier to discuss the issue in clinic. Pt was in a irritated mood. Pt walked out of clinic prior to completion of office visit. Nurse Practitioner student from university was also present in the room during the encounter.
none
schizoaffective, bipolar anxiety
not sure if taking benzotropine, haldol, chlorpromazine
nkda
declined neuro referral for Nerve conduction test on 11/6/2025