11/25/2019 Flu injection on 11/25/2021. Two days after vaccination left arm was still sore. All the listed appointments were for pain in arm, shoulder and reduced range of motion. The pain increased to the level of a chronic pain leaving patient fatigued when performing daily tasks.  12/7/2019 Provider: Assessment: pain, suspect related to recent influenza injection with some focal swelling, likely due to immune reaction. Plan: warm compresses and sleeping with a pillow popped on her arm discussed. Advised to keeping the shoulder active. Advised ibuprofen 600 mg 2 to 3 times per day with acetaminophen 500 to 650mg 2 to 3 times per day.  12/13/2019 Provider: Assessment; Myalgia, Normal exam. Unclear etiology. Labwork all normal  PLAN: Lab Work, Medrol Pack & naproxen for pain & immune suppression/inflammation reduction. If ongoing concern, may need MRI.  12/19/2019. Provider: Primary Care Physician                           Assessment: Patient is a 68-year-old woman who got her flu shot in the left arm about 4 weeks ago. She had the regular kind of soreness for a couple of days, and then got progressively worse and moved progressively more proximal. She has really had a lot of pain in her shoulder ever since. The pain can vary somewhat in severity. At its worst, it is probably a 7/10. Sometimes it is 2 or 3/10 and tends to be worse with certain movements and later in the day. She is right-handed but finds she can do a lot of things with her left hand. Naproxen plus Tylenol helps a little bit. She has been seen a couple times by other providers and was given a course of Medrol. She took steroids once years ago and could not sleep, but this time after just 1 dose, she felt very emotionally labile and so decided to stop it. She does not remember having that reaction before. No paresthesias. She feels like it might be getting weak, though that may be difficult for her to differentiate from the pain. No other joints bother her. There was a pretty clear relationship between receiving the flu shot and the development of the symptoms, though the pain in the first couple days did not seem to involve the shoulder itself as much as just the arm.  Plan: Shoulder pain that developed after high-dose flu shot. It seems like some inflammatory process was initiated by the flu shot. She did not have any pre-existing symptoms in the area, but it also seems that her flu shot was not given near the shoulder capsule, so this is likely a significant local inflammatory reaction to the shot. We discussed that it is likely to get better on its own over time, so our goal is mostly to see if we can manage the symptoms while we wait for that to happen and we have had marginal success doing that so far. We decided to try a Toradol injection today. I wonder if a different subclass of NSAIDs might help more, and we discussed that the potency of the Toradol is higher. We are going to see if she can receive it in her glute rather than her arm just to be on the cautious side. She is also set up to see Sports Medicine. Given her aversion to taking systemic steroids, we are going to try and avoid that, but maybe it is possible that a steroid injection could be helpful locally. If the Toradol is really effective, we are going to switch her NSAID to either oral Toradol or diclofenac, which is in the same subclass. If it is not effective, we are going to have her continue the naproxen as is and add some very low-dose prednisone until she goes to see the Sports Medicine specialist, which is scheduled for next week. She is cautioned about adverse effects of the NSAIDs. She seems to be tolerating them okay thus far.  12/23/2019 Provider: Assessment:  MUSCULOSKELETAL EVALUATION:  Neck ranges full, pain-free.  Shoulder range shows no signs of scapular dyskinesis or crepitus.  She has good shoulder abduction and forward flexion, actively tested to greater than 160 bilaterally. She has some mild limitation in internal rotation on the leftside probably about 10 degrees compared to the  right, but otherwise external rotation is full.  She has pain inhibition with shoulder abduction testing. STRENGTH TESTING: She has pain inhibition with shoulder abduction and external rotation testing, but no objective weakness sensation.  Sensation,reflexes are intact.  Palpable tenderness over the anterior glenohumeral joint line. No pain over the AC joint.  No pain below the lateral acromion.  No pain over the posterior glenohumeral joint. PROVOCATIVE MANEUVERS:  She has a negative drop arm, a positive painful arc, a negative Neer's, a negative Speed's, Yergason's, and crank.  A positive Hawkins.  A negative cross-arm adduction.  Positive empty can. IMAGING: Focused ultrasound shows no signs of bursitis or bursal distention with subacromial space evaluation.  No clear rotator cuff tear is visualized in infraspinatus, supraspinatus, teres minor, or subscapularis.  No subcoracoid effusion is identified.  Plan: We will do a corticosteroid into the subacromial space to address the bursitis. Follow up as needed.  She will likely improve, and I did recommend that she go off the anti-inflammatories in about 5 days.   1/3/2020 Provider: Assessment: She does not report substantial improvement in left arm/shoulder pain after the injection that we performed that day. That was a subacromial bursa injection. Pain continues to be limited with her rotation, and movement of her arm across her body still causes pain and is somewhat restricted. She has difficulty sleeping, and she thinks about this regularly. She is concerned for rotator cuff tear formation. She is here for followup and likely diagnostic ultrasound scan.  Her pain intensity at general is a 5/10, and for interference with enjoyment and general activity are 8 and 8. She has been using anti-inflammatories for pain relief, but otherwise does not use any medications.  PLAN: 1. We discussed that the next step here would be to proceed with a diagnostic intra-articular injection. Please see procedure note for details. 2. Followup phone call in about 2 weeks to assess level of improvement. 3. I reviewed the pathophysiology associated with adhesive capsulitis with the patient and the phases involved in this clinical manifestation. 4. She will follow up on an as-needed basis.  1/14/2020: Patient called pain is reduced. Was advised to go to physical therapy. Expectation is this will be the only cortisone injection necessary. Range of motion is the same.