Age: 55.0
Sex: M
Vaccine: FLU3, PPV
Symptoms: Red blood cell sedimentation rate, Spinal myelogram, Vaccination site pain, Vasculitis
Clinical narrative: 2013: October 17, AM: Received flu and pneumonia vaccinations in office of personal physician. Flu shot in left upper arm. Pneumonia shot in right upper arm. October 18, PM: Began having chills and fever. Arms aching at vaccination sites. October 19, AM: Fever spiked to 102; placed call to doctor on call. Advised to go to emergency room for allergic testing if condition worsened. PM: Fever stayed in 101's all day, along with extreme chills. October 20: AM: Fever began to back off, but still experiencing chills and muscle pain in arms. October 21: Fever gone but still having muscle pain in upper arms. Saw Dr. for pain in arms, along with D.C. for upper body muscle pains. November 1: Saw chiropractor. Muscular pain in both upper arms at injection sites. November 7: Saw Dr. for muscular pain in both arms. November 11: Saw chiropractor, for muscular pain in both arms. November 15: Saw chiropractor for muscular pain in left shoulder and upper arm, also right upper arm. November 18: Saw Dr. for muscular pain in left arm and shoulder, also right upper arm. Arm still numb at vaccination site. Dr. prescribed Prednisone 10 mgm, #7, and ULTRAM 50 mgm, Q. 6 hrs. November 22: Saw Dr. for muscular pain in left upper arm and shoulder, also right upper arm. Muscular knots across shoulders and upper arms. Arm still numb at vaccination site. Dr. increased prednisone to 20 mgm., #11, and prescribed PERCOCET 5-325mgm. November 22: Saw chiropractor for muscular pain in left upper arm and shoulder, also right upper arm. Muscular knots across shoulders and upper arms. November 25: Saw chiropractor. Left arm remains sore; right upper arm better. November 28: Right upper arm pain from pneumonia injection gone, left upper arm still sore from injection, but improving. Pain in upper arm focused at flu shot injection site. December 2: Began having muscle soreness in right forearm. NEW SYMPTOM. December 3, PM: Began having severe stabbing pain in right forearm, with pain traveling into right hand. Right thumb became numb. Index finger and middle finger also became numb within days. Severe pain in index and middle fingers, also palm of right hand. Developed paralysis in right index finger, middle finger, and thumb. December 5: Saw chiropractor-left arm/shoulder pain associated with injection slowly improving; severe pain in right fingers and hand, right forearm still sore; no pain in right upper arm. December 12: Saw chiropractor-left arm/shoulder pain associated with injection improving; severe pain in right fingers and hand, (R) forearm mild pain; no pain in right upper arm. December 16-20: Saw chiropractor each day; left arm/shoulder pain associated with injection improving-only medium level pain; right fingers/hand still severe pain. December 23: MRI of cervical spine. Left side pain associated with injection is medium level. December 24: Performed routine yard work and house work in preparation for holiday visitors. December 25: Began having severe pain in left shoulder with pain and limited mobility in left arm - cannot lift left above head. Pain in upper left arm focused at flu shot injection site. NEW SYMPTOM. Still have severe pain in right hand at thumb, index and middle fingers. December 30: Referred to another Dr. for steroid injection in left shoulder. Prescribed Prednisone 10 mgm tabs, #21. Also prescribed PERCOCET 10-325 mgm tabs, every six hours. Severe pain in left shoulder with pain and limited mobility in left arm. Pain in upper left arm focused at flu shot injection site. Right hand and thumb, index and middle fingers still in pain with paralysis. 2014: January 2: MRI of left shoulder. January 8: Saw chiropractor. Left shoulder and arm immobile; right hand and fingers still in pain; right arm better. Extreme pain in left shoulder when arm is lifted above head. January 13: Cervical epidural. January 14: Consultation with Orthopedic Dr. regarding left shoulder. MRI of left shoulder showed no problems according to Dr. Referred to Neurology for nerve testing. January 17: Saw chiropractor. Left shoulder and arm immobile; right hand and fingers still in pain. Extreme pain in left shoulder when arm is lifted above head. January 20: Follow up with Dr. after cervical epidural. Left shoulder and arm still immobile; right hand and fingers still in pain. Referred to another Dr., Neurosurgery. January 20: Nerve testing performed at Neurology. Referred to Neurosurgery. January 22-24: Saw chiropractor. Left shoulder and arm immobile; extreme pain in left upper arm and forearm; left hand in pain and numb; right hand and fingers still in pain. Developed pain and paralysis in left index finger and thumb. January 24: Called neurology regarding post-nerve testing pain in left forearm. Prescribed Diclofenac 25 mgm, #20. Upper arm and forearm responded to NSAID. January 29: Initial consultation with Dr. Ordered further tests. February 5: MRI of Brachial Plexus; MRI of cervical spine; Lab tests: C-React Prot High Sens (hsCRP); Lab tests: ESR; February 6: Developed additional paralysis in left hand and wrist-cannot hold a glass upright in left hand; also extreme weakness in left hand/fingers. February 11: Myelogram. February 12: Second visit to Dr. Inflammation present in nervous system. Surgery is not an option until inflammation is reduced. According to Dr., the problems in the C-5 and C-6 areas shown on the cervical MRI are not nearly severe enough to cause the shoulder and hand problems. The MRI of the brachial plexus showed no problems. Dr. referred back to other Dr. for treatment to reduce inflammation. February 18: Visit to Dr. at Neurology. Dr. confirmed inflammation and prescribed IVIG infusion. Inflammation likely a result of immunization. February 20-14: IVIG Infusion administered in home by Home Health Care. March 20: Visit to Dr. No results from IVIG. Dr. prescribed a 500 mg. infusion of Prednisone. Pain and paralysis are still present in both hands. The pain is worse in the right hand, but the left hand is weaker. Paralysis affects the thumb, index and middle fingers on right hand and thumb and index finger on left hand. March 21: Visit to Dr. Received electrical stimulation on shoulder. No improvement. March 25: Infusion of Prednisone at Center. March 26: Infusion of Prednisone at Center. March 28: Infusion of Prednisone at Center. April 17: Visit to Dr. No results from Prednisone infusions. Pain and paralysis are still present in both hands. Left shoulder has limited mobility. Extreme pain in left shoulder when arm is lifted above head. Referred to Dr. at Clinic. April 28: Visit to Dr. at Clinic. Dr. conducted a physical exam and prescribed additional nerve testing. May 2: EMG testing at Clinic. May 6: Received report from Dr. Report noted peripheral neuropathy and vasculitis likely as a result of immunization. May 22: Visit to Dr. Pain is still present in both hands. Left shoulder has limited mobility. Extreme pain in left shoulder when arm is lifted above head. Paralysis is present in thumb and index fingers on both hands and middle finger on right hand. June 25: Visit to Dr. No changes in symptoms. Aug 13: Visit to Dr. No changes in symptoms. Sept 2: First visit to orthopedic institute for physical therapy evaluation. Prescribed by Dr. Sept 19: Visit to Dr. No changes in symptoms. Pain and paralysis still present in both hands. Left shoulder has limited mobility. Extreme pain in left shoulder when arm is lifted above head. Oct 1: Physical therapy. Oct 7: Physical therapy. Oct 9: Visit to Dr. for periodic checkup. No changes in symptoms. Pain and paralysis still present in both hands. Left shoulder has limited mobility. Extreme pain in left shoulder when arm is lifted above head. Oct 10: Physical therapy. Oct 13: Physical therapy. Oct 17: Physical therapy. Oct 22: Physical therapy. Oct 24: Physical therapy. Oct 27: Physical therapy. Nov 14: Physical therapy. Nov 17: Physical therapy. Nov 21: Physical therapy. Nov 24: Physical therapy. Dec 1: Physical therapy. Dec 12: Physical therapy. Dec 17: Physical therapy. Dec 17: Visit to Dr. Shoulder range of motion has improved as a result of the physical therapy. Can lift left hand over head, but cannot hold it for more than a few seconds before it falls back down. Pain and paralysis still present in both hands. Numbness around injection site has disappeared. 2015: Jan 14: Physical therapy. Jan 26: Physical therapy. Feb 2: Physical therapy. Feb 6: Physical therapy. Mar 13: Physical therapy. Mar 19: Physical therapy. Mar 26: Visit to Dr. The range of motion for the left shoulder continues to improve. Can lift left arm straight over head. Pain in left shoulder is reduced. Pain and paralysis still present in both hands. Apr 22: Physical therapy. Last visit since range of motion in left shoulder has been restored. May 20: Visit to Dr. Pain and paralysis still present in both hands. Left hand and wrist strength has improved slightly. The pain is worse in the right hand, but the left hand is weaker. Paralysis is still present in the thumb and index finger on the right, but the middle finger is better. The middle finger has mobility, but still has numbness. Paralysis is still present in the thumb and index finger on the left hand. June 29: Next scheduled appointment with Dr.