Age: 44.0
Sex: M
Vaccine: FLUC4
Symptoms: Arthralgia, Limb immobilisation, Mobility decreased, Pain, Sleep disorder
Clinical narrative: I had pain in my left shoulder immediately following my injection. I told myself that I must be getting weak as I hadn't felt like that with any previous vaccinations I have received. By the time I went to bed I couldn't raise my arm above my head. I suffered through the night unable to sleep with a pain level of about 6. The next morning the pain reduced to about a 4 as I moved the arm more throughout the day. This same cycle repeated itself over and over for the next week and a half each night the pain grew worse until it was a 9 out of 10 and was so bad it would take my breath away. The next morning I went to urgent care. After urgent care I had 4 months of physical therapy with no relief. I then had a cortisone  Shot into my left shoulder which gave me relief for only a few weeks then the pain returned. My doctor then recommended surgery to fix the problem. I had a arthroscopic procedure with bursectomy and shoulder decompression. I am now 5 weeks post surgery still with pain and doing physical therapy 2 times per week.   1. Dates: 10/21/2020 2. Locations/Providers: Occupational Therapy 3. What you told them: I told him that my shoulder was still bothering me and keeping me up at night. 4. What you recall they did/said/prescribed: I was placed on light duty at work and prescribed acetaminophen and diclofenac. I was told to try ice and warm moist heat.   1. Dates: 11/04/2020 2. Locations/Providers:  Occupational Therapy 3. What you told them: I told him that my shoulder was still bothering me and keeping me up at night. 4. What you recall they did/said/prescribed: I was to continue light duty at work and prescribed acetaminophen and diclofenac. I was told to try ice and heat. I was referred to Dr. and physical therapy.    1. Dates: 11/11/2020 2. Locations/Providers: Occupational Therapy 3. What you told them:  I told him that my shoulder was still bothering me and keeping me up at night. 4. What you recall they did/said/prescribed: I was to continue light duty at work and prescribed acetaminophen and diclofenac.  I was told to continue physical therapy.  1. Dates: 11/23/2020 2. Locations/Providers:  Occupational Therapy 3. What you told them: There is still  no change in my pain. 4. What you recall they did/said/prescribed: I was to continue light duty at work and prescribed acetaminophen and diclofenac.  I was told to continue physical therapy. I was referred for xrays and an MRI.   1. Dates: 11/27/2020 2. Locations/Providers: Occupational Therapy 3. What you told them: I was still having pain.  4. What you recall they did/said/prescribed: He told me my MRI showed inflammation that was caused by the injection I received on 10/01/2020. I was diagnosed with a SIRVA and I was to continue light duty at work and prescribed acetaminophen and diclofenac.  I was told to continue physical therapy. I was referred to an orthopedic surgeon.  1. Dates: 12/29/2020 2. Locations/Providers:  Orthopedic Surgery 3. What you told them: I was still having pain. I said physical therapy wasn't really helping. 4. What you recall they did/said/prescribed: He went over my MRI results. He gave me a cortisone shot in my left shoulder and said that if it didn't solve the problem he would recommend surgery.  1. Dates: 01/13/2021 2. Locations/Providers:  Orthopedic Surgery 3. What you told them: I said that the cortisone shot made a big difference and really helped.  4. What you recall they did/said/prescribed: I was taken off work restrictions.   1. Dates: 03/02/2021 2. Locations/Providers: Orthopedic Surgery  3. What you told them: I told them that the shot wore off and the same pain came back and was back to a 7 out of 10 and I wasn't able to sleep. 4. What you recall they did/said/prescribed: Dr. suggested that I needed a shoulder arthroscopy, bursectomy, and decompression to fix it since the cortisone shot didn't work.  1. Dates: 04/09/2021 2. Locations/Providers: Orthopedic Surgery 3. What you told them: Still having pain.  4. What you recall they did/said/prescribed: On 04/09/2021 Dr. performed a left shoulder arthroscopy, bursectomy, and decompression to fix it since the cortisone shot didn't work.