Received Nov 25, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| PNC21 | PNEUMO (CAPVAXIVE) | MERCK & CO. INC. | 1 | U8767CA | IM / LA |
Patient received the flu vaccine in her left upper extremity 10/22/25. She experienced significant pain at time of injection. The pain did not resolve and remained present for 5 days. The pain worsened but is now not getting any better. Referred to orthopedist who states "likely has aggravated subacromial space and rotator cuff tendinitis after the immunization."
Hypertension, Hypothyroidism
None
Atenolol, Crestor, Synthroid, Wellbutrin
None
MRI demonstrate 1. Rotator cuff tendinosis with low-grade interstitial tearing. 2. Subacromial bursitis. 3. Anterior superior labral tear. 4. 4 mm focus of enhancement in the dermal soft tissues lateral to the deltoid muscle at the level of the surgical neck of the humerus which may represent recent site of injection. No fluid collection/abscess. as per radiologist [name withheld] MD