Age: 44.0
Sex: F
Vaccine: FLU3
Symptoms: Arthralgia, Magnetic resonance imaging abnormal, Muscular weakness, Pain, Pain in extremity
Clinical narrative: 9/21/24- Got flu shot, arm becoming more sore as the day went on 9/22/24-9/27/24 Arm continues to be painful and weak. It hurts to move it in certain ways. 9/28/24 I rolled on my right arm/shoulder while sleeping and woke up in severe pain that kept me up for an hour and a half. Took Advil PM 9/29/24 shoulder pain woke me in the middle of the night. Took a while to fall back asleep until the Advil kicked in 9/30/24 Called Dr.'s office to set up an appointment to see if she could help. 10/1/24 Had to use a half sick day to go to my doctor's appointment.               She prescribed a steroid, Naproxen, and a topical cream. I called Pharmacy to see if the meds were ready. They told me that they couldn't be refilled yet. The cause was that my doctor accidentally sent them prescriptions to the mail order pharmacy who filled the prescriptions and put them in the mail. It will take 3-4 days for the medications to come in the mail. Dr. then sent the prescriptions to Pharmacy. I had to pay out of pocket to get the medications sooner than they would come in the mail.  10/2/24 woke up in a lot of pain this morning. I couldn't reach around my back to fasten my bra. I took Naproxen to help with the pain.  10/2/24 began taking steroid pack and naproxen together. My arm began to feel a lot better after a couple days on the steroid.  10/8/24 finished steroid pack- pain started coming back worse as time went on. 10/10/24 The pain is back as bad as it was before I began the steroid pack so I made an appointment with an Orthopedic doctor for 10/10/24 at 2:20 pm.  The orthopedic doctor diagnosed me with vaccine induced frozen shoulder (adhesive capsulitis). He wrote a prescription for two steroid packs since I would be on vacation. He ordered an MRI and physical therapy. I still have naproxen from my primary care doctor to take as needed.   10/12-20/24 While on the steroids and naproxen, the pain was mildly uncomfortable and hurt more when I moved it certain ways.    10/21/24 finished both steroid packs. 10/23-27/24 Pain started getting progressively worse since the steroids wore off. When I didn't take naproxen during the day, the pain began to wake me up at night. I would take naproxen when it woke me up but it took over an hour for the pain to lessen enough for me to fall asleep again.    10/30/24 I get shooting pains from my shoulder down my arm when I move it certain ways.   11/4/24 MRI completed- was painful taking my arm in and out of the holder they put it in. Pain continues in arm when moved in certain ways. Naproxen helps but doesn't take all of the pain away. 11/12/24 I had to take a half sick day to go to the orthopedic doctor about the results of my MRI.                Dr. said that I have a tear in my rotator cuff and my options are PT, Cortisone shot (he said that just masks the pain) or surgery. His recommendation was to make an appointment with the surgeon. 11/19/24 Appointment with Dr.. He decided to take the conservative route and try a cortisone shot. He said to come back in 4-5 weeks for a follow up appointment.  11/20-12/2/24 My shoulder felt better but still hurt when I reached behind my back 12/2/24 Full pain is back. Constant ache, pain when I raise it above shoulder height, pain when reaching to the right and left and when reaching behind my back.  12/6/24 I had to take a ½ sick day to go to an appointment with Dr. (orthopedic surgeon).  Surgery scheduled for 12/18/2024                      I had to take a sick day on 12/18/24, 12/19/24, and a half sick day on 12/20/2024 (half day of school)  12/18/24 Went in for surgery at 1:30 pm                 Nerve block in through neck                Anestesia                Took oxycodone as prescribed for when the nerve block wore off                Sling  12/24/24 Post-op appointment with surgeon (Dr.)                Rest and do at-home exercises for 2 weeks and then start PT twice a week for 4 weeks. Follow up appointment on 1/28/25.