Received Dec 10, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE) | SANOFI PASTEUR | 1 | UT8829BA | IM / RA |
Pain at injection site, initial encounter Ongoing since influenza vaccine Discussed range of motion and use of heat Discussed continued use of biofreeze and muscle rubs as it was providing some relief Additionally, the patient is experiencing significant, persistent myalgia in the right deltoid muscle for over a month following an influenza vaccination, suggestive of a localized inflammatory reaction likely related to the injection. A steroid pack will be prescribed to reduce inflammation and soreness in the right deltoid muscle. The patient is advised to continue gentle range-of-motion exercises for the affected arm and to avoid immobilizing it.
Benign essential hypertension Bilateral primary osteoarthritis of knee Cyanocobalamin deficiency History of osteopenia Hx of heart artery stent Hx of myocardial infarction Hx of transient ischemic attack (TIA) Hyperlipidemia, unspecified hyperlipidemia type Iron deficiency Iron deficiency anemia secondary to inadequate dietary iron intake Lung nodules Microalbuminuria due to type 2 diabetes mellitus Type 2 diabetes mellitus with other specified complication, without long-term current use of insulin Vitamin D deficiency
aspirin calcium carbonate-vitamin D3 carvedilol clopidogrel cyanocobalamin (vitamin B-12) ergocalciferol (vitamin D2) ferrous sulfate ferrous sulfate-C-folic acid fluticasone propionate isosorbide dinitrate losartan nifedipine pravastatin t
oxycodone, tramadol