Age: 48.0
Sex: F
Vaccine: TDAP
Symptoms: Headache, Inflammation, Injected limb mobility decreased, Muscle spasms, Pain in extremity
Clinical narrative: -Tdap given on left arm on 2/1/24 at PE   PT went to see Neuro 2/5/24 for routine issues and nothing mentioned:  Left cervicothoracic radiculopathy -PT -Baclofen 5mg BID PRN -PRN ibuprofen -EMG done -Following with Neurosurgery, patient opts for conservative therapy   #Mild left carpal tunnel -left wrist bracing at night if symptoms arise   #Migraine with aura -given samples of Nurtec   #Low back pain -Doing stretching and massage -Will consider PT   PT called us 2/6/24 and note says: PT reports her left arm started hurting a few hours after started hurting a lot. She had a TDAP shot on Thursday. She said she barely could move it for days. No redness or swelling. She has full range or motion but sore now. She said she feels like she worked out and was really painful. She has only had regular TD in the past so she will just ask to not have TDAP again. Currently pain is a 4 and achy. On Thursday it was a 10/10.     She was encouraged to ice and take OTC tylenol and/or Advil. She also had a headache 2 days ago. She was encouraged to move arm around. Added TDAP to intolerance and encouraged to call with any worsening or changing SX. Denies any other symptoms.   PT went to UC on 2/11/24 for same issue: PLAN:   -Radiology imaging, report reviewed.  Negative for acute pathology.  Low suspicion for infection.  Have started patient on prednisone taper.  Patient states that she has taken steroids in the past and tolerated well.  Recommend continued icing, gentle stretching and NSAIDs or Tylenol.  Advised patient that if she does take NSAIDs with steroids she should also take Pepcid to prevent against gastric bleeding, gastric irritation.  Recommend follow-up with PCP for reassessment.  Advised to return for worsening discomfort, redness, swelling, fevers, any new or concerning symptoms.  Patient agrees with plan.  All questions answered.   PT seen by PCP 2/12/24: Has full ROM but it hurts. W/in 2 hours of vaccine had excruciating pain. Went to UC and doing steroid taper. Inflammation is decreasing. Was doing ibuprofen tyelnol and Voltaren and icing. So much pain can barely sleep until steroids which helps mildly. Had massage and elt better for a few hours, then pain got worse. So afraid to do anything to make it worse. Second active with it flares up badly. Worst motions above 30 or reaching behind causes a lot of pain. Positive Hawkins.  . Pain in joint of left shoulder (Primary) Assessment & Plan: ? Rotator cuff impingement possibly due to swelling after TDaP vaccine Steroid taper helping, but still having significant pain Will refer for sports med for further workup and recommendations (? Steroid injection)  Will give robaxin as she has used in the past and doesn't make her sleepy as the pain is making her tense up and causing other pains Can also try diazepam as she has significant anxiety around this and muscle spasms so this might help with both, but patient understands it may cause drowsiness and to use sparingly    Orders: -     MRP Orthopedics Other orders -     diazePAM (VALIUM) 2 MG tablet  Dispense: 7 tablet; Refill: 0 -     methocarbamoL (ROBAXIN) 500 MG tablet  Dispense: 60 tablet; Refill: 1  PT saw Dr. at Orthopedics on 2/16/24: PLAN: I believe the patient has some acute bursitis after the vaccine injection.  She has gotten better on the prednisone I offered her a cortisone injection but she has a problem with needles.  We will hold off on the cortisone injection she will finish her prednisone as well as a taper ice limit her activities based on comfort and she will follow-up in a few weeks if not improved or sooner if she decides she wants a cortisone injection.   PT called us that afternoon and this was telephone encounter: Note     PT was referred to the Orthopedics specialist (Dr) and had an appointment today. He diagnosed her Bursitis. He did offer the steroid injection. She is extremely nervous about this.    - she thought she was referred to him for an ultrasound. I explained in the note it appears she was referred there for possible steroid injection.    -Spoke with "X" and she mentioned Dr. uses ultrasound guided injections so may be a better option. Spoke with patient and she is interested in a consult. She was advised they will call her to schedule the consult.    PT saw Dr. on 3/7/24   Pain in joint of left shoulder (Primary) Assessment & Plan: Patient has shoulder pain which represents bursitis.  This is likely related to the immunization she received.  I discussed treatment options including anti-inflammatory medications and physical therapy.  She is wary of having a cortisone injection.  I therefore recommended therapy.  She will follow-up in 6 weeks if this persists