Age: 65.0
Sex: F
Vaccine: FLU4
Symptoms: Injection site joint effusion, Injection site pain, Injection site reaction, Muscular weakness, Nuclear magnetic resonance imaging abnormal
Clinical narrative: September 24, 2018 - I had a flu shot at Pharmacy. On the drive home, I felt a crawly sensation under my skin at the injection site like an insect moving under my skin. This continued on and off for a few days.   Between October 15, 2018 and October 30, 2018 - I had left arm and hand tingling with low-grade pain and a little weakness. I did self-care remedies: sling, Motrin 800mg, heat, ice, and bedrest.  October 30, 2018 - I had a routine appointment with my cardiologist, and I mentioned these symptoms to him because I thought it could have something to do with my heart although I do not have heart problems. I told him that I had a flu shot. He said we would keep a check on it.   By November 16, 2018 - The pain was excruciating, so I saw my primary care provider (PCP) on November 13, 2018. No treatment was given. She said the pain would go away because the flu shot is given in a muscle.   Between November 17, 2018 and November 30, 2018 - The pain in my left shoulder was severe. I continued to do self-care remedies as mentioned above. I went to my PCP on December 7, 2018 with excruciating shooting, burning,stabbing, aching pain and unable to move my left arm or my left shoulder. My PCP ordered x-rays in house, told me there was no impingement, gave me a cortisone shot at the top of my shoulder close to my neck, and scheduled physical therapy for me. The PCP would not give me a diagnosis after my daughter and I made several requests for one. Physical therapy provided a little relief with movement, but no relief from pain. The physical therapist told me the pain was in my neck and he would massage my neck and place me in traction. That made me sick, so I would not allow him to continue that therapy. I told him that the pain was in my shoulder, not in my neck. Physical therapy began on December 13, 2018 and ended on January 30, 2018.   December 28, 2018 - I went to my PCP for a follow-up. The pain was still severe, but I had a little more range of motion. Again, I requested a diagnosis, but none was given. She told me to take over-the-counter Motrin or Advil.   I continued to have severe pain through January of 2019. I called my PCP on January 14, 2019 and requested an MRI. She referred me to shoulder Orthopedist I. I was given an appointment a month later, and I couldn't wait that long, so I sought help at another facility on January 29, 2019. Orthopedist II ordered x-rays of my neck and left shoulder. He did no examination and gave me no diagnosis. He said the pain was in my neck, not in my shoulder. I told him the pain was in my shoulder. Two months later, I began to request all records because I knew that I was not being treated fairly. I discovered that he had diagnosed cervical radiculopathy which I don't have and never had!   February 6, 2019 - I kept the appointment with Orthopedist I. He did no examination, gave me no diagnosis except to say that there was shoulder impingement, and I needed rotator cuff surgery.   When I received his copy of my record I discovered that he copied Orthopedist I's report and said that I had cervical radiculopathy. He prescribed Solu-Medrol Dose Pack 4mg and Nabumetone 750mg. There was no relief. The pain was overwhelming. I began to do research at this time to find what my real problem was.   February 18, 2019 - I saw my PCP and again I asked for a diagnosis. She gave Orthopedist II's diagnosis to me repeatedly. By this time I knew what my problem was, but I wondered why the medical practitioners were hiding it from me by withholding a diagnosis and fabricating a diagnosis. I knew that I had been suffering with adhesive capsulitis.   February 20, 2019 - Pain was somewhat less in intensity, but I went to the Emergency Room at a local hospital, and the doctors diagnosed adhesive capsulitis and gave me research on the disease. They were quite upset that my doctors did not give me a diagnosis or had an MRI done.   February 22, 2019 - I saw Orthopedist III. He said that I had symptoms of adhesive capsulitis which was in the thawing stage by this time. He ordered an MRI of my left shoulder on February 28, 2019.   March 7, 2019 - The MRI results showed hypertrophy of the acromioclavicular joint; capsular distention; fluid in the subacromial and subdeltoid bursa; Infraspinatus and supraspinatus tendinosis; intrasubstance tear of the infraspinatus at its myotendinous junction; and glenohumeral joint effusion. I presented with adhesive capsulitis on December 7, 2018 at my PCP's office and a clinical diagnosis should have been made then. (On July 29, 2019 my PCP admitted that I had adhesive capsulitis when I was in her office on December 7, 2018 because I told her that I knew what my condition was.)   March 7, 2019 - I called my PCP to arrange for physical therapy at a facility of my choice due to on-going pain, weakness, and loss of motion. I started physical therapy for the second time on March 20, 2019 and ended on May 27, 2019. The exercise regimen was tailored for adhesive capsulitis although they were guarded about telling me this. I had done the research, so I knew. When I was assessed at the new facility, I had 42% of range of motion and strength out of 100% in my left arm and shoulder. As I exercised at this facility, range of motion and strength improved, but I was still in pain, though greatly lessened. Night time pain was and still is a problem.   April 4, 2019 - I saw Orthopedist IV. He did a thorough examination and ordered x-rays. He assessed left shoulder pain, a left shoulder rotator cuff tear, and left shoulder tendinosis. He prescribed Diclofenac Sodium Topical Gel 1% and Lidocaine and Tetracaine 7%/7%. My shoulder was still painful with limited range of motion. He referred me to Orthopedist V for further assessment and possibly a surgical remedy.   May 7, 2019 - I saw Orthopedist V. He did no examination and made no diagnosis except to look at my MRI images to show me where my rotator cuff was torn and damaged in three places. He prescribed Prednisone 10mg and Motrin 800 which helped the pain tremendously. The only time this doctor touched me to examine me was to ask me to brace against his hands to measure rotator cuff strength. Yet, he has written up this elaborate medical record on me detailing what he found.   July 29, 2019 - I saw my PCP for routine lab results, and I confronted her about my diagnosis. She admitted that both she and the attending physician knew that I had adhesive capsulitis.   September 11, 2019 - I will see Orthopedist VI for further evaluation and possibly surgery. I have shoulder pain every minute of the day and night - worse at night. Until my situation is resolved, I will request another stint at a physical therapy facility.   I did not list doctors' names because I am going through legal channels if these physicians are not sanctioned through their hospitals or professional organizations. I will reach out to them near the end of this month. If you must have the names, I will provide them.   I told every doctor I saw that I had a flu shot, and they began to deny that my problems were a result of the vaccine. Some said they did not know that there was such a thing as flu shot complications; some became angry because I reported that my problems occurred after I had the flu shot; and some doctors withheld a diagnosis, fabricated a diagnosis that did not exist, and fabricated medical records to hide what they had done.