Age: 53.0
Sex: F
Vaccine: TDAP
Symptoms: Anti-cyclic citrullinated peptide antibody, Blood uric acid, Dyspepsia, Injected limb mobility decreased, Injection site discomfort
Clinical narrative: Pls see attachments. 12/22/11 Vaccine given - (L) deltoid IM. 12/23/11 localized discomfort/heaviness - upper arm. left noted upon waking up in the morning. No fever, no redness, no swelling of (L) upper arm. Discomfort was noted to be persistent as days went by but I was hoping it will eventually disappear because I had no fever, no redness and no swelling at the injection site. 03/15/12 Pain noted at the left upper arm while lying down on the lateral side, relieved if repositioned to free and the from pressure. Clinic where the vaccine was administered made aware. MD contacted by phone, ordered warm compress at the site of injection for 1-2 weeks; to come back if no improvement. 03/29/12 No improvement. More pain at the upper arm noted with certain movements of the left upper extremity. LVN at clinic reported to MD - was instructed to report to clinic for evaluation by occupational medicine specialist. Dr ordered x-ray of left shoulder, 3 views - according to him it was normal, "it is only muscular." He further added that "it is not necessary to order for other diagnostic work-ups" MDs orders: Modified duty, apply hot packs, ibuprofen 800 mg PO Q 8 with food. 04/09/12 Received a call form physical therapy clinic scheduling of PT session. 04/10/12 Started PT. 04/11/12 Follow up with dr - no improvement - pain was going up to the left shoulder joint. - limitation of movement of left shoulder joint observed MDs orders: continue PT, continue ibuprofen, continue hot packs & prednisone 5 mg PO - 21 tabs given - tapering scheduled dose, modify duty. 04/26/12 PT last day of the six sessions ordered. No improvement. Partial temporary relief of pain noted after ultrasound was administered by PT. 05/01/12 5-6/10 Left shoulder pain- early AM - includes base of the nape area. + Limitation of movement of the left shoulder joint still no fever, no swelling, no redness, MDs order: continue ibuprofen as ordered, modified duty; continue hot packs. 05/15/12 Burning sensation at the epigastric area with ibuprofen intake. Tightness of (L) upper arm muscle. Limitation of movement of left should joint. Gnawing pain in early AM; No fever; no redness noted. No swelling; + tenderness (L) shoulder/upper arm. MD's orders: MRI, continue previous meds, continue hot packs, omeprazole 20 mg po q daily 30 minutes before breakfast. 05/18/12 MRI done. 05/29/12 No improvement. MRI results with MD. MD's orders: continue all meds; Modified duty follow up: June 08, 2012. 05/30/12 Following day - received a call for Head of clinic at the hospital - I was informed that I have been released from Workmen's Comp basing on the result of MRI. I was so devastated because I was still suffering from pain, tightness and limitation of movement of the left shoulder joint. Primary Physician consulted with same complaints - lab work-ups (dose with results), - chest x-ray ordered (done with result) - Mammogram ordered (done with result) - routine/yearly Med: CELEBREX 100 mg cap 1 po q daily with meal. 06/06/12 Since I am the breadwinner in the family, I opted to return back to my nursing job in the ward/floor. It was very difficult decision but I had not choice. The pain is slightly controlled by the NSAID but the tightness and the limitation of left shoulder joint movement is still there. Unguarded wrong movement causes severe shooting pain at the left upper arm. 05/13/12 Follow-up with PMD; No improvement PMD's orders: Ortho consult; continue CELEBREX.