Age: 60.0
Sex: F
Vaccine: FLU3
Symptoms: Tenderness, Ultrasound scan normal
Clinical narrative: Initial report was received on 12 December 2011, from a healthcare professional. A 60-year-old female patient received an Intramuscular (IM) injection of FLUZONE; lot number UH470AD in left deltoid on 18 November 2011. On an unspecified date, the patient complained of pain in area posterior to deltoid area where injection was given. The patient left arm hurts with movements; feels "full" on palpation and tender to touch. No further informational was available at the time of the report. The patient outcome was reported as not recovered/not resolved. Follow-up information was received from a health care professional on 12 March 2012. The patient still had left deltoid area soreness. The patient had an MRI and an ultrasound (US) that were both negative. The patient planned to see an orthopedist as left upper arm remains very painful. The patient was treated with non-steroidal anti-inflammatory drugs (NSAID's) and ice to the area. The patient's outcome remained not recovered. Follow-up information was received from a health care professional on 04 May 2012. The patient was seen on 06 April 2012 for the chief complaint of left shoulder pain. The patient's history of present illness was that the patient had the FLUZONE shot in the lateral deltoid region of the left shoulder on 18 November 2011. The patient had pain in the lateral aspect of the shoulder and posterior aspect of the shoulder. Since then, the shoulder has progressively been having more pain. The patient was starting to lose range of motion and cannot lift overhead. Many doctors have told the patient to use warm compresses but the pain was persistent. The physical examination of the left shoulder on 06 April 2012 revealed some tenderness of the posterior distal deltoid region with little bit of a palpable fullness in that region. No fluctuance, no known erythema, forward flexion of 145 today limited secondary to pain, external rotation is 75 limited secondary to pain laterally and posteriorly. Internal rotation is quite limited with pain posteriorly about 45 degrees today. The patient had 5/5 strength globally throughout all three rotator cuff muscles today with slight pain on testing of each. Positive impingement, positive Hawkins, negative cross arm abduction and no tenderness of the AC joint. The MRI of the left humerus was negative. The diagnosis impression was status post left posterior deltoid flu shot with probable small amount of scar tissue and early adhesive capsulitis left shoulder. The treatment recommendations reported the patient indicated for a left shoulder subacromial intra-articular injection to try to decrease the inflammation of early adhesive capsulitis and work on her range of motion. The patient received a left shoulder intra-articular and subacromial corticosteroid injection of 3cc marcaine, 3cc lidocaine and 60mg DEPO-MEDROL. The patient had great relief of pain after the injection. She could lift her arm at least 50% higher after the injection. The patient was encouraged to do a home exercise program consistent with stretching of the forward flexion plane, internal and external rotation planes and will follow-up in four to six weeks for evaluation. The patient's outcome remained not recovered. Documents held by sender: None.