Received Jan 9, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| TDAP | TDAP (BOOSTRIX) | GLAXOSMITHKLINE BIOLOGICALS | 1 | 5GY34 | IM / RA |
On 12/17/2025 Patient states right arm pain following Tdap vaccination, right arm discomfort began on 12/5/2025. Per provider no evidence of severe or systemic reactions; localized tenderness appears consistent with an adverse reaction to the vaccine. Symptoms are gradually improving, characterized by localized muscle soreness limiting certain arm movements. - No significant palpable mass currently noted; previously reported lump at injection site has reduced in size. - No infection signs observed, no imaging indicated at this time. - Recommended ibuprofen or acetaminophen as needed for pain relief. - Advised to rest the arm and minimize activities that exacerbate discomfort. - Instructed to monitor for persistence or worsening symptoms over the next one to two weeks. Treatment plan Your pain and soreness appear to be related to muscle irritation and possible nerve pressure from the injection. The lump at the injection site is going down, and there are no signs of infection or swelling. - You may take ibuprofen 400 mg or Tylenol as needed for pain. - Try to rest your arm and avoid activities that make the pain worse. - If your symptoms are not improving within the next week or two, or if they get worse, please let us know. Patient returned to office on 1/2/2026 for Persistent right upper arm pain localized over the deltoid muscle, noted after tetanus toxoid injection. Right shoulder/upper arm: Pain with abduction; able to abduct fully with good range of motion. Mild residual tenderness of lower deltoid muscle. Per provider no tenderness localized to shoulder joint or elbow , lumps have resolved, and there is no residual induration or neurological deficit. Tx plan as followed Prescribed Celebrex 200 mg daily, quantity 30 with 1 refill. - Advised use of extra strength acetaminophen up to four times daily as needed for breakthrough pain. - Referred for physical therapy to initiate an exercise program. - Recommended follow-up evaluation in 1 month. Start CeleBREX 200 mg capsule 1 capsule every day
none
GERD, Hypothyroidism
Flonase Allergy Relief 50/mcg nasal spray, Prevacid 24Hr 15 mg capsule, delayed release
aspirin, azithromycin, Bactrim, cortisone, latex, oxycodone, penicillin, oxycodone, sulfamethoxazole-trimethoprim, Zithromax, Zithromax Z-Pak