Received Dec 9, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| HPV9 | HPV (GARDASIL 9) | MERCK & CO. INC. | 2 | Y019459 | IM / LA |
| VARCEL | VARICELLA (VARIVAX) | MERCK & CO. INC. | 2 | Z008197 | SC / LA |
Patient reports developing left arm pain after the vaccines. It worsened after a traumatic blood draw later that day (with multiple punctures and ecchymosis visible today 8 days later). He has difficulty dressing himself and writing in school. On exam, left upper arm was slightly swollen, ROM markedly restricted, refusal to allow arm elevation above shoulder height due to pain, held arm in internal rotation. He was referred to orthopedic surgery for further evaluation and management.
hypercholesterolemia, obesity, elevated blood pressure, chronic daily headache.
This occurred on initial visit and establishment of care
none
none
deferred to ortho.