Received Dec 9, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| TDAP | TDAP (BOOSTRIX) | GLAXOSMITHKLINE BIOLOGICALS | 1 | PX3P7 | IM / RA |
The patient received a Tdap vaccine in the right arm on 09/30/2025. After the vaccination, the patient developed right shoulder pain, which persisted and prompted a return visit to the clinic on 10/03/2025. The patient reported that the pain began after the injection and was located in the shoulder area rather than the typical deltoid muscle region. Upon evaluation on 10/03/2025, Dr. assessed the injection site and noted that the vaccine appeared to have been administered slightly higher than the recommended deltoid location. Clinical Supervisor, RN, also examined the area and confirmed this finding. The patient was monitored and no signs of infection were observed. The patient received clinical evaluation and follow-up instructions. Documentation was completed, and staff were reminded of proper deltoid landmarking to prevent future high injection placement.
8/5/25 - Nasal congestion and sinus pressure, Recent URI symptoms, Allergic rhinitis, Cardiac symptoms. 9/30/25: Fatigue, shortness of breath with palpitations, numbness of right lateral foot after injury, and tick bite of right thigh. "Had flu-like sx 1 week after tick bite over the summer. Soon after that, he developed some palpitations, which have since come and gone. They have been more consistent over the past 3 days, feeling symptoms about once every minute. They will feel like he has an extra beat and associated shortness of breath, but it resolves within a few seconds. He will then repeat every minute. He never had a bull's-eye rash."
None
NKDA
10/23/25 - RIGHT SHOULDER FLUOROSCOPY GUIDED ARTHROGRAM INJECTION MRI RIGHT SHOULDER ARTHROGRAM