Received Apr 16, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| PNC21 | PNEUMO (CAPVAXIVE) | MERCK & CO. INC. | 1 | Z013321 | IM / RA |
Patient is a 27 year old female with recent right upper extremity cellulitis who presents for follow-up of a right arm reaction after a pneumonia vaccine. She received a pneumonia vaccine in the right arm on Fri 3/20/26 and then developed progressively worsening right upper arm pain with erythema, warmth, and firmness, with markedly decreased range of motion at peak intensity last weekend (unable to move the arm; touch-intolerant). She had a low-grade fever on Sat 3/21/26 and went to the ED on Sun 3/22/26, where she was started on cephalexin (Keflex). Since starting cephalexin on Sun 3/22/26 (4 pills/day for a planned 10-day course) and using naproxen for pain, symptoms have steadily improved. She reports full range of motion with little to no pain, and mild sensitivity in a few spots. She reports that the redness is less than before, warmth went away around Wednesday, and she has not had any further fevers. She documented the course with photos earlier in the week when erythema appeared to be spreading and notes continued improvement since then. Patient denies any recent fevers, chest pain, shortness of breath, abdominal pain, dizziness or syncope. All questions were encouraged and answered to patient's satisfaction.
UTI - 3.13.26
Narcolepsy Mild exercise-induced asthma Migraine Chronic pain of right knee PTSD (post-traumatic stress disorder) Irregular menstrual cycle Chronic female pelvic pain Excessive hair growth Acne, unspecified acne type Abnormal uterine bleeding (AUB) Class 1 obesity with body mass index (BMI) of 30.0 to 30.9 in adult PCOS (polycystic ovarian syndrome) Class 1 obesity due to excess calories without serious comorbidity with body mass index (BMI) of 31.0 to 31.9 in adult Incomplete tear of right rotator cuff, unspecified whether traumatic Gastroesophageal reflux disease without esophagitis Generalized anxiety disorder Female hirsutism
albuterol HFA (PROVENTIL HFA, VENTOLIN HFA, PROAIR HFA) 108 (90 Base) MCG/ACT inhaler busPIRone (BUSPAR) 5 mg tablet LORYNA 3-0.02 MG per tablet nitrofurantoin (MACROBID) 100 MG capsule omeprazole (PRILOSEC) 40 mg delayed-release capsule ph
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