Received Feb 2, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| PNC20 | PNEUMO (PREVNAR20) | PFIZER\WYETH | 1 | MH9572 | IM / LA |
Patient arrived to Medical Care Health Center on 12/19/2025 for his vaccine appointments. PCV20 administered on left upper deltoid and TdaP administered on left lower deltoid. Flu vaccine administered on right deltoid. Patient called Call Center on 1/07/2026 to report pain on left arm stating he received two vaccines on his left arm and is experiencing pain on left arm and unable to reach for objects, use utensils turn steering wheel or lift arm above shoulder without experiencing deep pain in joint. Patient had follow up appointment with provider same day, who ordered MRI of his upper LE, a referral to PT was placed, and diclofenac sodium 1% gel was prescribed that day as well. Patient had follow up appointment on 1/23/2026 with his PCP Dr. [name withheld] who reviewed the MRI result with him: "Signal abnormality of the infraspinatus tendon with peritendinous edema and overlying marrow signal changes most consistent with provided history of suspected SIRVA. Small area of posterolateral deltoid muscle edema and enhancement, likely injection related. Superior labrum degeneration." At discharge during this 1/23/2026 visit, PCP instructed patient to take 600 mg of ibuprofen twice daily PRN for shoulder pain, to take with food and apply the diclofenac gel as needed 4 times a day.
Paresthesia of both lower extremities, Bilateral Carpal Tunnel Syndrome, Localized swelling of both lower legs, Poor Nutrition, Sedentary Lifestyle
Pancytopenia, Dyslipidemia, Iron overload, Erectile dysfunction
None
NKA
MRI of upper LE ordered on 1/07/2026 and this result reviewed by patient's PCP during follow up appointment with patient on 1/23/2026