Reporte zur Charge NDC 70461032003

Symptomtext

09/22/2020 - I received a Flucelvax Quad 2020-2021 flu vaccine via syringe in my left shoulder at the pharmacy. The vaccine site was swollen and hot for about 7 days. Deep shoulder pain began along with excessive Ibuprofen use to try to manage pain. Sleep difficulties due to waking with severe, deep shoulder pain that lasted for hours. 10/05/2020 - Office Visit with PCP/NP due to shoulder pain. Diagnostic tests and referrals were discussed. Cause was unknown at the time. No previous history of shoulder pain and/or injury. X-rays were taken in the office to determine if a fracture or dislocation had occurred. Neither were present on the x-ray. PCP/NP prescribed Gabapentin and Lidocaine for pain. She instructed me to discontinue Ibuprofen due to concern that I was experiencing possible abdominal symptoms related to the overuse of Ibuprofen. PA discussed options, including MRI and PT, if pain continued. 10/23/2020 - Follow-up office visit with PCP/NP. Gabapentin was discontinued after first day due to side effects. Referred to a pain specialist. Flu vaccine prior to the shoulder pain was addressed. 12/03 - MRI completed as ordered by Pain Specialist, Dr. MRI Findings are: FINDINGS: *Moderate Supraspinatus and Infraspinatus Tendinosis with mild adjacent fluid in the subdeltoid subacromial bursa suggesting bursitis. *A 13 mm x 14 mm tear of the supraspinatus tendon. *Mild atrophy of the supraspinatus muscle. *Type 2 curved acromial configuration without undersurface spurring. *Advanced cartilage loss in the acromioclavicular joint with mild adjacent spurring. *Mild to moderate capsular thickening and increased signal suggesting adhesive capsulitis. 12/08/2020 - Follow-up visit with Dr. - recommendation of Physical Therapy 2-3 times weekly for 8 weeks to support self-healing of the supraspinatus tear if possible. Dr. stated that the "almost full thickness supraspinatus tear with absence of attachment distally" may require surgery. I continue to experience deep, left shoulder pain. Limited range of motion. Severe pain and "crunching" sound when arm is lifted or when it receives any pressure against it (lifting self from tub/bed, etc.). Follow-up appointment with Dr. will be scheduled for February 2021.