Received Jan 22, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| PNC20 | PNEUMO (PREVNAR20) | PFIZER\WYETH | 1 | MH1447 | IM / LA |
12/04/2025, patient contacted clinic asking for advise on worsening pain at injection site. patient states he received immunization and is having soreness denies pain currently, denies swelling, redness or heat coming from the area. Patient given ER precautions in case symptoms should worsen patient verbalized understanding. Patient stated he will take Tylenol as prescribed day of visit to alleviate intermittent soreness. 12/10/2025- Nurse Called patient to triage. Confirmed patient using 2 patient identifiers. Patient reports mild pain at immunization site (left deltoid) since receiving PCV 20 vaccine on 11/24/25. States he has been taking 1 pill of ibuprofen once before bed for the pain. Patient denies fever, rash, swelling, or shortness of breath. Reassurance provided to the patient. Discussed heat pack or warm wet washcloth on the vaccine shot area for 10-20 minutes and repeat as needed. Discussed continuing pain medication OTC for the next 1-3 days. He verbalized understanding. Callback instructions provided. 12/15/2025- patient was seen in clinic by provider. Pain noted to be intermittent; noted on left deltoid, location where the vaccine was given. Pain to the area is a 4/10 to the deltoid area. Pain sometimes radiating to lower arm. Denies swelling to arm/shoulder/deltoid area. No redness. No other reaction noted. Has used Tylenol for the pain minimal relief. No numbness noted. Pain sometimes noted with range of motion of the left shoulder. Denies: Chest pain/shortness of breath. 12/30/2025- Patient is requesting a call back today in regards to an injection he got on 12/15/2025. He is in pain and he is not able to work due to the pain from the injection. 1/13/2026- Left Arm Pain: Has not received his PT referral. Continues with left arm pain; noted to be constant. Pain noted mainly noted at nighttime. Pain is a 8/10. Taking Ibuprofen which has not helped. Patient concerned as the pain has not decreased. Able to move his arm; however, pain noted with movement. No swelling to the arm. 01/22/2026- patient reached out to clinic, no improvement on left arm pain.
Type 2 diabetes with Hyperglycemia, without long- term use of insulin. Hyperlipidemia, unspecified hyperlipidemia type. Soft tissue mass (Resolved), Tinnitus aurium, bilateral. Thoracic back pain, unspecified back pain laterality, unspecified chronicity.
Atorvastatin, synjardy xr
No known allergies
Patient was referred to physical therapy, and orthopedic surgery for evaluation and treatment of left arm pain. Patient has not attended referrals. Patient received normal x-ray of the humerus results.