Age: 54.0
Sex: F
Vaccine: FLU4
Symptoms: Joint noise, Loss of personal independence in daily activities, Malaise, Migraine, Mobility decreased
Clinical narrative: Two and here days later tongue burning, large dark red spots/areas on tongue, could not move tongue well and could not eat (too painful), cracking areas on tongue. Right foot/heel and hip became so painful/hard to walk, pain kept worsening into joints of feet toes right shoulder. Was not able to use stairs at work, too painful and hard to move. Pain in ankles, walking was very unstable and difficult due to pain and coordination issue. Had bad migraines for several days at base of neck/skull. Nausea, burning in mouth, esophagus and then down into stomach (could feel burning pain) Ended up going to clinic and sent to Hospital for stomach burning, Had developed infection in gut. Given two medications did not stop working to have checked out unit it had moved into stomach. So busy at work tried to push through every day but ended up with gut infection and then had to take off October 23, 2019-flu shot administered. Three days later tongue burning, large dark red spots/areas on tongue, could no move tongue or eat, cracking tongue Right foot/heel and hip so painful could not walk right Pain worsened and had pain in joints in feet, toes, big toes and heels, right shoulder, could not move up. Could not lift horse feed or anything heavy. Had to have someone muck stalls Was not able to use stairs at work always took elevator from feet hurting so bad and could not move ankles right. Walking weird and slow Put salenpos patches on feet and wrists, and shoulder but did not bring enough relief Ibuprofen and Tylenol gave little relief Had bad migraines for several days at base of neck/skull and moved up. Nausea feeling Had burning in gut and mouth Stomach pain so bad and fever 102.8 and 103 could not break fever and pain worse. Ended up at clinic and could not go to work. (was ready for work that morning and told not to come in because of fever-probably good that happened since I went straight to clinic Sent to e.r. upper region with infection in gut Given two strong antibiotics Out of work for a week but tried to work some at home to keep up Back to work, did not concentrate well. Seemed like pain and confusion made it hard to work. Had to try hard to stick with task and concentrate Burning still in gut even after meds but seemed like infection gone. Lost of burning and indigestion feeling in chest and gut. Liquid diet for awhile and still have to eat real light stuff No energy and pains in wrists, shoulder and feet and still hard to walk. Took off two weeks around holidays to try to rest and recover. By date January, 2020 still in pain. Pain every day feels worse in the night and early morning. Labored to breath, feels like it is a chore to breath and it is uncomfortable. It takes a long time to get moving. Feet and ankles are not working right and have to wear shoes that comfort, like soft slippers or tennis shoes or slip on soft boots. Slowed down too much. No intimacy and not much energy to do anything. Shoulder clicks and gets so hard to move and cannot pick things up Pain while sleeping so cannot get a full night sleep Cannot do regular chores and it's causing problems at home. Could not book trip to go with husband's family because feel like I cannot get out of my own way. Concerned that going back on January 6, 2020 will be hard to get through days because of paint and moving badly. Hard to bend over or stoop down. Cannot hardly push myself up from stoop because arms and wrists feel like they are breaking and knees. Body overall feels really heavy to pick up. Afraid going to loose job because seems like they won't understand what's going on. Still having problems with what I can eat because of burning and nausea. Swelling in fingers and still a lot in fingers and feet and legs. 1/7/20 saw Dr. at 7:50 a.m. to have adjustment (hoping pain to stop) 1/3/20 difficulty walking, numbness in hands off and on. The patient is a pleasant right-hand dominant female, who presents to clinic for a scheduled clinic appointment. She is a well known patient of Dr.'s practice. She has been previously followed for her right hip pain issues. She is actually here for a new concern. She states that her shoulder pain started in October 2019, shortly after receiving the flu vaccination. She states that she also had several other issues/constitutional symptoms to include malaise, non specific abdominal pain, secondary bilateral hip and knee and nonspecific joint pain. The patient was treated conservatively to include RICE therapy, oral analgesics and activity modification along with rest. When asked if she has participated in outpatient physical therapy for her right shoulder, the patient states no. The patient has not received an intra-articular cortisone injection of right shoulder joint. In the patient's opinion that she believes that she did have an adverse, potential allergic reaction from the flu vaccination. She states prior to that, she was not having any specific shoulder pain. She denies any noted falls, traumas or injuries that precipitated her shoulder pain. She can only account that it happened shortly after she received the flu vaccination in her right upper extremity/right deltoid region. Today, she denies any constitutional symptoms at this time to include no fevers, no chills, no shortness of breath, no chest pain, no bowel or bladder dysfunction. She does experience intermittent dumbness or tingling sensation that radiates down her right arm. She denies any numbness or tingling sensation for this visit for either upper extremity. She has modified her ADLs. She describes her pain as a dull type of throbbing ache. She localizes her pain to her right proximal shoulder and deltoid region. She rates her pain as a 5-6/10. She continues with RICE therapy protocol along with the use of oral analgesics/NSAID therapy p.r.n. She has modified her ADLs/occupational duties accordingly. She is here today for further assessment and evaluation.