Received Feb 13, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| PNC21 | PNEUMO (CAPVAXIVE) | MERCK & CO. INC. | 1 | Z013321 | IM / LA |
Nurse visit 2/12/26--Patient c/o reaction to P21 vaccine received at routine appt with PCP on 2/9/26 in her left deltoid. Patient states her symptoms began about 4 hours after the injection was administered. She states she had fever for 48 hours with 101 being the highest temp. along with loose stools, HA, nausea that followed after the initial 48 hours of fever. Patient reports her left deltoid was splotchy with red patches but used ice pack and it has resolved since. Had some dizziness but that has also resolved. C/o numbness/tingling that started at site of injection and has progressively radiated down to her left hand and up to left shoulder and neck. Reports left eye began twitching this morning and she became concerned. Patient denies SOB, chest pain, any rashes and/or blistering, difficulty swallowing. She states under her left arm was red and tender at left axilla. C/o pain in left deltoid is 8/10, but 6/10 under left arm. VS obtained and WNL. No erythema, warmth, edema, odor, drainage, open areas noted at site of injection or surrounding area. Observed no visual difference from anterior perspective when comparing right axilla to left axilla. Some warmth noted slightly but explained axilla tends to be more warm and is expected finding. No palpation of enlarged lymph node in left axilla. Patient states this is reassuring since she had breast exam completed at the time of injection by PCP which was also normal then. Patient declined any need for further intervention and chose to monitor symptoms at home, mainly wanted it noted in her record of the reaction. Follow up phone call completed to check on symptoms 2/13/26- Patient reported she only continues with slight numbness/tingling in left extremity but is feeling slight improvement compared to yesterday. Patient was educated that the pain described correlates with nerve pain which may take time to resolve. She is to contact clinic if it persists next week. She is to monitor symptoms and with any chest pain, difficulty breathing/swallowing, rash, swelling, shortness of breath, worsening numbness/tingling, muscle weakness she is to call EMS and report to the nearest ER for further evaluation.
Plantar fasciitis - "Better"; UTD.com information provided on foot pain, including exercises. Patient can use Diclofenac cream topically. Pt has inserts already. PT saw podiatry, She was encouraged to wear larger sized shoes. Ear mufflness - Resolved w/Zyrtec 20mg. Due to sore in L nare, recommended avoidance of Flonase spray at this time. Left-sided low back pain/ R knee pain /chronic back pain - Knee XR shows mild arthritis. She is using diclofenac cream topically for symptom relief. Patient aware that if she continues to experience pain, I would encourage her to do physical therapy. - Patient feels left-sided low back pain is associated with her GI distress as this typically worsens along with bowel movement/constipation. IBS-C - GI rec low FOBMPOP diet to improve IBS-C. Amtriptline also helps without it, she has diarrhea. Low BMI - Patient back taking Vanilla Ensure daily. Patient states she weighs herself monthly and keeps her eye on her weight. Improved, 121 lbs. Headache/Dizziness/Occ Neuralgia/ H/o Subarachnoid hemorrhage 2011- Continue ubrogepant (50 -> 100mg) PRN, also on Elevil. Patient encouraged to go to the emergency room with any visual symptoms, temporal pain, confusion/incoordination, or worsening headache. Pt feels dizziness does occur more depending on her hydration/nutrition status. - Behind R eye she expereiences migrane. Pt continues to follow with the neurologist. Leucopenia - Stable. No major changes since last labs, will will continue to monitor. Per hematology, reconsult if any changes. Hyperlipidemia - Patient on Rosuvastatin 10 mg daily. Tolerating well. Nodule of lung - Patient continues to follow with pulmonology & surgeon. She has been following with thoracic surgeon (MD). - Following with pulm clinic, Chest CT yearly ordered 8/2026, pt provided guaifenesin tabs, aerobika PEP valve, advised to continue saline nebs. Wrist pain bilaterally - Improved.
A Pulmonary emphysema (SCT 87433001) (ICD-10-CM J43.9) 08/06/2025 A Asthma (SCT 195967001) (ICD-10-CM J45.20) 03/31/2025 A Exposure to potentially hazardous substance (SCT 133261000119105) (ICD-10-CM Z77.29) 03/11/2024 A Plantar fasciitis of left foot (SCT 12241271000119101) (ICD-10-CM M72.2) 12/11/2023 A Bronchiectasis (SCT 12295008) (ICD-10-CM J47.9) 03/24/2023 A Malnutrition (SCT 2492009) (ICD-10-CM E63.9) 08/10/2022 A Migraine without aura (SCT 56097005) (ICD-10-CM G43.009) 12/21/2021 A Occipital neuralgia (SCT 71760005) (ICD-10-CM M54.81) 12/21/2021 A Sequela of non-traumatic intracranial subarachnoid haemorrhage (SCT 723085008) (ICD-10-CM I69.098) 12/21/2021 A Leucopenia (SCT 84828003) (ICD-10-CM D72.819) 07/28/2021 A Hyperlipidemia (SCT 55822004) (ICD-10-CM E78.5) 07/29/2020 A Nodule of lung (SCT 786838002) (ICD-10-CM R91.1) 07/29/2020 A Dizziness (SCT 404640003) (ICD-10-CM R42.) 11/21/2017 A Insomnia (SCT 193462001) (ICD-10-CM G47.00) 03/22/2017 A Subarachnoid hemorrhage (SCT 21454007) (ICD-10-CM I60.9) 03/22/2017 A Chronic back pain (SCT 134407002) (ICD-10-CM M54.5) 03/22/2017 A Headache (SCT 25064002) (ICD-10-CM R51.9) 01/27/2021
AMITRIPTYLINE HCL 10MG TAB ACTIVE/SUSP 180 02/10/2027 02/09/2026 04/23/2026 3 TAKE TWO TABLETS BY MOUTH AT BEDTIME FOR PAIN, SLEEP, OR MOOD ROSUVASTATIN CA 10MG TAB ACTIVE/SUSP 45 07/25/2026 07/24/2025 04/10/2026 0 T
NKDA
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