Age: 42.0
Sex: F
Vaccine: FLU3
Symptoms: Asthenia, Bursitis, Fatigue, Hypoaesthesia, Impaired work ability
Clinical narrative: 11-04-15 - received flu shot. 11-05-15 - had muscle soreness as usual but seemed to be deeper than usual. 11-06-15 - still had soreness deep in shoulder but typical muscle soreness associated with shot was gone. Up until 11-20-16 still had problem with shoulder. I experienced limited movement, weakness, numbness and pain. Along with that the muscle in the shoulder at base of neck have been tight compensating for it. Because of what I do for a living I cannot work like that for safety purposes so I ended up making an appointment with my doctor but was not able to get in until December. It was discussed and decided it could be an industrial as the flu clinic was brought to our work and is promoted by the city (my employer) to be vaccinated. Paperwork was then completed and I was sent to be seen through industrial. 11-20-15 - I went to be seen. X-rays were done to check for bone spurs and nothing was found. I was then prescribed Naproxen, given a sling to wear as needed to keep from using it and placed on light duty status until follow up appointment. A follow up apt was scheduled for 11-27-15. In the meantime it was decided it was not an industrial claim and would not be covered. Since could not get in to my regular doctor for a month I ended up going back to the clinic to be released to full time or extend light duty. 11-27-15 - I returned to clinic to be seen. Pain was continuing as well as limited movement and numbness. I was told to continue the Naproxen and my light duty status was extended until another follow up date of 12-04-15. In the meantime I was to get an MRI done on my shoulder. Results were asked to be forwarded to both clinic and my regular doctor I was scheduled to see. 11-30-15 - MRI done. 12-04-15 - I went back to clinic and was given the results of the MRI. This stated everything appeared normal except for the following statement "There is infiltrative appearing fluid signal noted just below level of the a.c. joint and the distal clavicle overlying the rotator interval which may represent some combination of bursitis and reactive soft tissue edema. There is trace fluid noted in the subscapularis bursa adjacent to the coracoid process". My light duty status was continued until my appointment with my regular doctor. 12-15-15 - I went to dr at medical center. I was told to continue Naproxen as needed and was prescribed VOLTAREN gel to use. I was also referred to physical therapy. And a follow up appointment was made for 6 weeks later as directed by the doctor. I asked to be released from light duty and was released at that time but told to monitor the injury until follow up appointment. I attended PT overt that time period but do not have those dates available right now. I can get them though if they are needed.01-27-16 - follow up visit with dr at medical center. I was given a steroid injection in the shoulder and told to monitor how it is doing and advised it cannot be given an earlier than every 3 months due to complications. Over this time the pain is reduced but is still there depending on usage. I can feel that these is something still not right in it and sometimes is worse than others. Continued problems with tiredness, achiness and tightness in muscles but it all varies depending on usage.