Received Jun 9, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA MNEXSPIKE)) | MODERNA | 1 | 3052996 | IM / LA |
Patient complained of left sided shoulder pain that persisted since 4/22/26. He also complained of difficulty sleeping with pain. Patient has been treated with voltaren gel, advil and tylenol.
none
high blood pressure, heart related issues
Patient received the Moderna (mNexspike) covid vaccine on 04/22/2026 in the left shoulder (deltoid). That same day he developed left-sided shoulder pain that persisted. He complains that it still hurts to move his shoulder and has sleep d
no known drug allergies
May 18th, 2026- Urgent care visit: Physical exam, Xray of arm (showing AC joint arthrosis and calcific tendinosis and improving from last may)-deciding on whether this is a shoulder injury from vaccine vs calcific tendinosis. Referred to orthopedics. On May 21st went to sprots medicine. Vitals were taken and normal. Xray showed moderate acromioclavicular joint arthrosis and mineralized densities along the anterior proximal humeral metaphysis suggestive of calcific teninosis at the pectoralis attachment versus loose bodies within the biceps tendon sheath. Diagnosis included: Rotator Cuff strain, left initial encounter, arthritis of left acromioclavicular joint, and left shoulder pain unspecified. Administered corticosteroid injection. Also advised against NSAIDS due to increased GI bleeding risk and recommended tylenol. Proved home exercises for shoulder strengthening. Also advised physical therapy if pain persists.5