Received Nov 20, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 5 | 8146751 | IM / LA |
The patient is a 48-year-old female presenting for evaluation of left arm pain that began after receiving a COVID-19 vaccination approximately two weeks ago. - She reports the injection itself was unusually painful, which she has not experienced with prior vaccinations. - The pain progressed throughout the day, and for the first 2-3 days post-vaccination, she experienced severe pain that made it difficult to lift her arm, wash her hair, or take off her shirt. - While the initial severe pain has lessened, she continues to experience a constant ache and jolting pain with certain movements, such as reaching forward. - She also reports intermittent sensations of her arm falling asleep and some tingling, though this has improved. - Symptoms were exacerbated over the weekend by carrying grocery bags. - She has been taking Advil, which provides some relief. - She denies any fevers, redness, or swelling at the injection site. - She denies any other injury, exercise, or workout around the time of the vaccine that could account for these symptoms. - She has never had a similar reaction to a vaccine before.
1. Benign Paroxysmal Positional Vertigo 2. Seasonal Allergies:
Past Medical History: ? LGSIL on Pap smear of cervix 05/2023 scheduled for LEEP 11/2023
- Loratadine - Lo Loestrin - Advil as needed for pain
Latex
To be competed on 11/21/25