Report #2892472

Received Apr 11, 2026

Office visit

A note on interpretation. VAERS reports are unverified and may be incomplete or coincidental. A report does not establish that a vaccine caused an event, and counts should not be used to calculate incidence or infer causation. Full disclaimer

Overview

Sex: Male
Age: 64 yrs
State: CA
Recovered: Not recovered
Vaccinated: Feb 10, 2026
Onset: Feb 10, 2026
Days to onset: 0
Hospital days: —

Vaccines (1)

Type	Name	Manufacturer	Dose	Lot	Route / Site
TDAP	TDAP (BOOSTRIX)	GLAXOSMITHKLINE BIOLOGICALS	1	JX5K9	IM / LA

Symptoms (1)

Shoulder injury related to vaccine administration

Symptom narrative

SIRVA: CHIEF COMPLAINT HAD CONCERNS INCLUDING ALLERGIC REACTION. HISTORY He had an injection in his left arm for tetanus at our annual visit, he ha had ongoing pain every since. Limits ability to swim (crawl stroke) and do push up or yoga type activity. Painful daily waxes and wanes able to do some activity without much pain such as golf PHYSICAL EXAM Physical Exam Musculoskeletal: Comments: TTP high in upper deltoid area which is where he states injection was administered. Mild positive supraspinatus sign, pain with external rotation. ASSESSMENT & PLAN Patient was seen today for allergic reaction. Diagnoses and all orders for this visit: Shoulder injury related to vaccine administration (SIRVA) - Referral to Physical Therapy - Referral to Physiatry (PMR) For now use NSAID, will review with management. At this time, I recommend f/u with PT and sport medicine for ongoing management. Electronically signed by: M.D. 4/6/2026 2:25 PM

Medical history

Mixed hyperlipidemia Create Overview Unprioritized 11/7/2022 1:50:51 PM M.D. Chronic gout of left foot Create Overview Unprioritized 11/15/2023 1:40:11 PM M.D. Tophi Create Overview Unprioritized 11/15/2023 1:40:13 PM M.D. Ankle instability, right Create Overview Unprioritized 9/26/2024 8:25:44 AM Med Ass't Squamous cell cancer of scalp and skin of neck Create Overview Unprioritized 2/6/2025 10:03:43 AM M.D.

Other medications

colchicine (COLCRYS) 0.6 MG Tab Take 1 Tablet by mouth 3 times a day. Dispense: 30 Tablet, Refills: 1 ordered 02/10/2026 ? M.D. indomethacin (INDOCIN) 50 MG Cap Take 1 Capsule by mouth 3 times a day. Dispense: 30 Capsule, Refill

Allergies

NKDA

Lab data

ASSESSMENT & PLAN Patient was seen today for allergic reaction. Diagnoses and all orders for this visit: Shoulder injury related to vaccine administration (SIRVA) - Referral to Physical Therapy - Referral to Physiatry (PMR) For now use NSAID, will review with management. At this time, I recommend f/u with PT and sport medicine for ongoing management. Electronically signed by: M.D. 4/6/2026 2:25 PM