Age: 59.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Arthralgia, Feeling hot, Impaired work ability, Injection site pain, Injection site swelling
Clinical narrative: Patient presented to the clinic for evaluation on 12/14/2021 with chief complaint of acute left shoulder and arm pain with associated left swollen supraclavicular glands and soreness at injection site after having received the Covid-19 vaccine (Booster dose) on 12/9/2021. Right hand dominant.      Reported left shoulder and arm pain, soreness at injection site and swollen glands of the left upper shoulder began on 12/09/2021. (Note: patient reported initial reaction after the 1st and 2nd doses: mild fever, fatigue for several days, soreness at injection site). Described Adverse Event, Outcomes, Treatment:  Since onset of pain, how has your condition been: progressively worsened since 12/09/2021 How frequent is your pain: constant How severe is your pain (1-10): 5 today, wakes up with 2/10 pain, worsens with movement, worst pain 7-8/10 pain experienced. What does your pain feel like: throbbing, no shooting pain "it's just painful" "I don't know how to describe it, it's just there" Does your pain extend to any other part of your body: YES, pain extends left upper shoulder down the left arm to the left hand   Aggravating Factors: Worse with Movement of the left shoulder/arm, very painful if the arm is bumped or touched, clavicle is very painful/tender, does not like the bra strap touching the left shoulder. Does this limit work or activities: YES Does your pain keep you awake at night: sleeps, but will wake up at night with the pain What have you tried for pain: rest, Heat, Ice, Ibuprofen, Tylenol helps to take the edge off the pain, topical cream does not help. Guarding left arm     Do you have numbness or tingling in the arm or hand? No, however states the left arm/hand feels "weird sensation, not burning, feels hot, but is not hot"  There is no temperature change of the arm/hand, no cold sensation, pins or needles, stabbing or electrical shocks Is there any swelling/redness/bruising at the shoulder? YES--swelling and tenderness at the injection site and a bump or bulge on the left lateral arm--never had this before. There is no bruising or redness Do you have any weakness of the arm? No Have you ever had a history of shoulder surgery? YES--history of RIGHT shoulder rotator cuff surgery remote past Have you ever had shoulder pain before this current episode of pain? Never LEFT shoulder pain. No history of frozen shoulder   Other Symptoms Description: swelling and tenderness just above the left clavicle, sore/painful left clavicle, itchy skin just above the left clavicle and left upper arm. There is no rash present. Left Neck sore and "tight", left upper back sore, left axilla tender   ROS:  Per HPI. Denies fever, chills, bodyaches, chest pain, shortness of breath, wheezing, difficulty breathing, cough, headache, abdominal pain, nausea or emesis. Reports she had a migraine headache over the weekend, takes a prescribed migraine abortive medication (can't remember the name); reports a headache today. No visual changes, no dizziness. Reported her significant other commented that her breathing the first night after the vaccine sounded "gurglely", but that resolved. denies wheezing or worsening asthma symptoms Denies contagious ill exposures, no Covid-19 exposures in the past 14 days, no positive Covid-19 test in the past 10 days, no air travel States she currently does not have health insurance, but will have starting Jan. 1, 2022. Nonsmoker, quit over 11 years ago TREATMENT: symptomatic treatment: Naproxen 500 mg BID prn pain, OTC Tylenol 1000 mg TID prn pain. ICE or heat TID prn. biofreeze prn. Left arm sling daily for several hours as needed for comfort, advised not to wear continually. Maintain range of motion of the left shoulder to prevent and avoid shoulder adhesive capsulitis. Physical Therapy ordered for left shoulder/arm pain. Provided and discussed shoulder range of motion exercises specifically pendulum arm swing circles.  CBC with differential, CRP, and Ultrasound of the Neck/Head to evaluate supraclavicular lymphadenopathy.  The patient plans to wait to have any testing done until she has health insurance as of Jan. 1, 2021 due to out of pocket costs. Advised and discussed signs and symptoms that would prompt return to care, to ED/call 911 if emergent red flag symptoms. 12/17/2021: Follow up telephone encounter: patient reports  persistent left shoulder, arm, left neck and upper back pain with tender left supraclavicular adenopathy and left axilla tenderness s/p Covid-19 vaccine received on 12/09/2021.  A Medrol dose pack was prescribed to help lessen the acute pain and inflammatory response. 12/22/2021: Follow up encounter to assess response of Medrol dose pack. It will be 2 weeks on 11/23/2021 after receipt of the Pfizer Booster dose. The paient reported the left upper extremity pain is gradually improving, rates roughly 70% better though still experiencing intermittent persistent left shoulder, arm, left neck and left upper back pain with tenderness of the left supraclavicular area with less swollen tender glands, and tenderness of the left axilla. Taking OTC ibuprofen prn with some relief.