Age: 56.0
Sex: F
Vaccine: TDAP
Symptoms: Pain in extremity, Rotator cuff syndrome, Sleep disorder, X-ray limb normal
Clinical narrative: On August 26, 2021, I presented to my primary care physician (PCP) for a routine health assessment visit, without any specific physical complaints in the area of question; my musculoskeletal physical exam was normal. At the close of the visit, I was offered administration of the Tdap and Shingles vaccines. I accepted and received both vaccinations (right shoulder, Tdap, left shoulder, Shingles). I believe a Medical Assistant administered the vaccinations, however this information is not provided in the visit note.  Because of persistent symptoms (pain and limited movement) in my right shoulder beyond that which I would expect, which continued following the vaccine and were more evident given the typical transient post-vaccination soreness in my left arm, I emailed my PCP on September 4, 2021 to inform her of my concerns. Although the pain had improved with OTC NSAIDs, it was still present, worse in the morning with definite limitation in the range of motion.   I emailed again on September 7, 2021 to inform my PCP that the pain was better but still present, requiring 400 mg Motrin. I let her know again that the pain impacted my range of motion and this was the symptom that required pain relief; I was not taking Motrin to control localized soreness in the area of the injection. I also informed her that I only had pain on my right and that the pain that I experienced from the vaccine in my left shoulder was transient and consistent with that I had experienced with prior vaccinations.  On September 15, 2021, I had a virtual video visit with my PCP. She noted in the exam that there was pain with abduction and flexion. She recommended continued NSAIDs, X-ray and follow-up with Orthopedics.  On September 28, 2021, I had an office visit with the orthopedic surgeon. Although I acknowledged improvement in my symptoms over the last 4 weeks, I continued to note persistent discomfort in my right shoulder region with more pain while sleeping and stiffness (pain) in the morning upon waking. I complained also of increased pain when lifting my right arm up and away from my body. Per the visit note, my physical exam revealed ?some diffuse tenderness at the proximal deltoid and subacromial area. Impingement sign per se, is positive. She lacks the terminal few degrees of forward elevation and rotation.? The impression was ?Arthralgia? and the note read that I sustained some rotator cuff irritation secondary possibly to the vaccination. I was referred for physical therapy.  I had a virtual PT visit on October 20, 2021. I described continued improvement but noted that symptoms were still present, with continued discomfort with movement and soreness on the day of the visit requiring OTC NSAIDs. The clinical impression was shoulder impingement. Shoulder exercises and a 4-week follow-up visit were recommended.  I was seen by the orthopedic surgeon on November 15, 2021 for a steroid injection secondary to persistent pain. I was seen January 19, 2022 with some mild discomfort with improvement following steroid injection with some recent shoulder discomfort. I had a telephone follow-up with the orthopedic surgeon on February 25, 2022 to discuss long term plan if symptoms increase (MRI, exercises, repeat injection). Because of constant low level but persistent pain symptoms, I have a followup in July with the orthopedic surgeon to discuss a second steroid injection.