Received May 13, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE) | SANOFI PASTEUR | N/A | U8875BA | IM / RA |
Left shoulder pain following administration of influenza vaccination: She reports that her right shoulder exhibited noticeable edema compared to the contralateral side and began experiencing dull pain during her workday, initially attributing the discomfort to the position of her computer mouse. The pain progressively worsened, ultimately inhibiting her ability to participate in gym activities. Despite resting for 45 minutes at a dog park, the pain persisted and intensified to a pulsatile sensation. She attempted various pain management strategies, including ice application, a heating pad, and a transcutaneous electrical nerve stimulation (TENS) unit, with ice providing the most relief. The pain is described as aching, without associated erythema or increased warmth, and she has been palpating the area to identify a trigger point. The pain has been constant and severe since onset, with no relief from over-the-counter ibuprofen 800 mg. Gabapentin is avoided due to its sedative effects. She did not experience neuropathic pain during the injection itself. The patient also experienced mild nausea associated with the shoulder pain. In an attempt to alleviate symptoms, she consumed a couple of alcoholic beverages at the park and a glass of wine at home, and took diphenhydramine, which caused drowsiness. Due to persistent symptoms, she called emergency medical services and was transported to the emergency department, where a computed tomography (CT) scan of the head and an x-ray of the arm were performed. She was informed that her blood pressure was hypotensive upon arrival. No head injury or fall was reported. Alcohol: The patient consumes alcohol, including a couple of drinks at the park and a glass of wine at home. On 3/24/26, she was treated at PCP with osteopathic manipulative treatment (OMT) including lymphatic drainage: OMT provided with successful mobilization of upper ribs, as well as lymphatic mobilization to reduce congestion to injection site. Patient reported immediate partial relief, pain reduction, and improved tolerability to aROM of right upper extremity. On 3/26/26 she reported to orthopedic evaluation due to persistent pain, who administered corticosteroid injection to the same shoulder. Patient reports that this was finally successful in significantly reducing her pain back to baseline. Ortho A&P "Right shoulder arthritis flare-up: Exacerbation of chronic shoulder arthritis likely triggered by recent vaccination, with swelling and discomfort noted. Previous mild symptoms and joint noises were present, but pain increased after vaccine administration. Cortisone injection into shoulder recommended and agreed upon to reduce inflammation and pain. Sling advised for comfort. Monitor symptoms; avoid strenuous activity and perform gentle range-of-motion exercises as tolerated. Risks discussed include temporary pain at injection site, infection, and possible increase in blood sugar. Goal is symptom relief and improved function. "
Gastroesophageal reflux disease without esophagitis Shoulder impingement, right Primary hypertension Nervous and Auditory Complex regional pain syndrome type 1 of right lower extremity Lumbar radiculopathy Arthritis Scoliosis Prosthetic joint infection, sequela Lumbosacral spondylosis without myelopathy Attention deficit hyperactivity disorder (ADHD), combined type Prediabetes Chronic midline thoracic back pain HLD (hyperlipidemia) Mild episode of recurrent major depressive disorder Iron deficiency anemia Physical deconditioning Overweight (BMI 25.0-29.9) Impaired mobility and ADLs Anxiety Status post revision of total hip replacement Chronic neck pain Elevated lipoprotein(a) Chronic pain disorder Leg length discrepancy
calcium-D2-magnesium-C-K2-min 166.6 mg-4.15 mcg-83.3 mg tab dextroamphetamine-amphetamine (ADDERALL XR) 30 mg 24 hr capsule dextroamphetamine-amphetamine (ADDERALL) 20 mg tablet docusate sodium (COLACE) 50 mg capsule evolocumab (Repatha Sur
Ambien [Zolpidem] Cat Dander DaptomycinShortness Of Breath Allerg Ext-tall Ragweed Pollen Cat Hair Standardized Allergenic ExtractHives Insect VenomItching, Other (See Comments) MoldOther (See Comments) Shellfish Containing ProductsDiarrhea, GI Intolerance Shellfish DerivedDiarrhea, Nausea Only, Other (See Comments) Weed Pollen-giant (Tall) RagweedOther (See Comments) CodeineItching, Nausea And Vomiting
XR Shoulder Minimum 2 Views Right Order: Impression IMPRESSION: No acute displaced fracture. Electronically Signed by: (withheld) on 3/24/2026 4:15 AM Narrative XR SHOULDER 2+ VIEWS RIGHT PROVIDED CLINICAL INDICATION: Other closed extremity injury with pain and/or deformity ADDITIONAL CLINICAL INDICATION: None available COMPARISON: None available INTERPRETATION: Moderate glenohumeral joint degenerative changes. No acute displaced fracture. Exam End: 03/24/26 03:05 Specimen Collected: 03/24/26 04:14 Last Resulted: 03/24/26 04:15 Received From: Health Result Received: 03/24/26 14:47 CBC And Differential Order: Ref Range & Units 1 mo ago WBC 4.0 - 10.5 10e3cells/uL 7.2 RBC 3.93 - 5.22 10e6cells/uL 3.60 Low HGB 11.2 - 15.7 gm/dL 11.5 HCT 34.1 - 44.9 % 34.9 MCV 79.4 - 94.8 fL 96.9 High MCH 25.6 - 32.2 pg 31.9 MCHC 32.2 - 35.5 gm/dL 33.0 Plt Ct 150 - 400 10e3cells/uL 282 RDW SD 35.1 - 46.3 fL 47.7 High MPV 9.4 - 12.4 fL 9.5 NRBC% 0.0 - 0.2 /100WBC 0.0 Absolute NRBC Count 0.00 - 0.01 10e3cells/uL 0.00 NEUTROPHIL % % 66.8 LYMPHOCYTE % % 23.7 MONOCYTE % % 7.7 Eosinophil % % 1.0 Basophils % % 0.7 Immature Granulocyte % % 0.1 Absolute Neutrophil Count 1.50 - 7.50 10e3cells/uL 4.80 Absolute Lymphocyte Count 1.00 - 4.50 10e3cells/uL 1.70 Absolute Monocyte Count 0.10 - 0.80 10e3cells/uL 0.55 Absolute Eosinophil Count 0.00 - 0.50 10e3cells/uL 0.07 Absolute Basophil Count 0.00 - 0.20 10e3cells/uL 0.05 Absolute Immature Granulocyte Count 0.00 - 0.03 10e3cells/uL 0.01 Resulting Agency MEDICAL CENTER Specimen Collected: 03/24/26 02:31 Performed by: MEDICAL CENTER Last Resulted: 03/24/26 02:44 Received From: Result Received: 03/24/26 14:47 h BUN 8 - 27 mg/dL 25 Creatinine 0.57 - 1.00 mg/dL 0.96 Calcium 8.6 - 10.2 mg/dL 9.5 BUN/CREAT RATIO 11 - 26 26 eGFR >=60 mL/min/1.73m2 64 Comment: Normal GFR (glomerular filtration rate) > 60 mL/min/1.73 meters squared, < 60 may include impaired kidney function. Calculation based on the Chronic Kidney Disease Epidemiology Collaboration (CK-EPI) equation refit without adjustment for race. Resulting Agency MEDICAL CENTER Specimen Collected: 03/24/26 02:31 Performed by: MEDICAL CENTER Last Resulted: 03/24/26 03:15 Received From: Health Result Received: 03/24/26 14:47 Magnesium Order: Ref Range & Units 1 mo ago Mg 1.6 - 2.6 mg/dL 2.0 Resulting Agency MEDICAL CENTER Specimen Collected: 03/24/26 02:31 Performed by: MEDICAL CENTER Last Resulted: 03/24/26 03:15 Received From: Health Result Received: 03/24/26 14:47 View Encounter Received Information Collection Information Collected: 3/24/2026 2:31 AM EDT