Received Nov 25, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE) | SANOFI PASTEUR | UNK | U8827AA | IM / LA |
Patient called 10/20/2025 to report concerns of arm pain in left upper arm after flu shot. She reports no initial soreness or concerns after injection, but that pain started about 2-3 days after shot. She states that pain level on 0-10 scale is no pain at rest, normal movements pain/discomfort about a 2 but worsens when she lifts her arm to side or raises above her head, gets significant pain up to a 6 or 7. Reports she can lift arm in front of her with no pain. Describes pain as sharp, almost like "pulled muscle" and says pain is in the outer area of her arm from mid-arm where she received the shot up to shoulder, some minor radiation to back of arm. Denies any swelling, redness, warmth, weakness, numbness, tingling, fever or any other symptoms. Pain does not stop her from daily activities but is disruptive in its unpleasantness and persistence as no improvement as of follow up phone call on 11/25/2025. Having significant pain causing difficulty when putting on jacket, brushing hair, trying to sleep on left side, crossing left arm over to right shoulder, etc... She had some concerns about vaccine placement too low on arm, review with nurse and patient indicate administration likely in lower portion of deltoid muscle. Patient reports minimal/no relief with heat or ice, or OTC Tylenol.
None reported in last week, did not ask about longer time frame and nothing reported
None reported
No antiviral medications, did not ask about others and none reported. No report of chronic illnesses on vaccine screening questions.
None reported
I consulted via phone with [withheld facility name] MD, Dr. [name withheld] of patients report of symptoms and experience. He has recommended evaluation by primary provider for any necessary imaging, rule out of potential causes, and treatment, etc... Pt given this recommendation on 11/25/2025 and reports she will make an appointment and let me know the outcome of visit.