VICP Registry Case Source Bundle
Canonical URL: https://vicp-registry.org/case/USCOURTS-cofc-1_23-vv-00940
Package ID: USCOURTS-cofc-1_23-vv-00940
Petitioner: Vicki Mullin
Filed: 2023-09-20
Decided: 2024-10-22
Vaccine: influenza
Vaccination date: 2020-11-11
Condition: shoulder injury related to vaccine administration (SIRVA)
Outcome: entitlement_granted_pending_damages
Award amount USD: 

AI-assisted case summary:
Vicki Mullin filed a petition for compensation under the National Vaccine Injury Compensation Program on September 20, 2023. She alleged that she suffered a shoulder injury related to vaccine administration (SIRVA) as a result of receiving an influenza vaccination on November 11, 2020, and that the residual effects of her injury lasted for more than six months. The case was assigned to the Special Processing Unit. Following a fact ruling confirming the vaccination occurred in her right shoulder as alleged, the Respondent filed a Rule 4(c) report conceding that Petitioner is entitled to compensation. Respondent specifically indicated that Petitioner suffered SIRVA as defined by the Vaccine Injury Table and satisfied all legal prerequisites for compensation. Based on the Respondent's concession and the evidence of record, the Chief Special Master found Petitioner entitled to compensation. The case is currently pending a decision on damages.

Theory of causation field:
Table

Public staged source text:

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DOCUMENT 1: USCOURTS-cofc-1_23-vv-00940-0
Date issued/filed: 2024-08-20
Pages: 7
Docket text: PUBLIC ORDER/RULING (Originally filed: 07/17/2024) regarding 20 Findings of Fact & Conclusions of Law, Signed by Chief Special Master Brian H. Corcoran. (nh) Service on parties made.
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Case 1:23-vv-00940-UNJ Document 24 Filed 08/20/24 Page 1 of 7
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 23-940V
VICKI MULLIN, Chief Special Master Corcoran
Petitioner, Filed: July 17, 2024
v.
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Jimmy A. Zgheib, Zgheib Sayad, P.C., White Plains, NY, for Petitioner.
Joseph Adam Lewis, U.S. Department of Justice, Washington, DC, for respondent.
FINDINGS OF FACT1
On June 23, 2023, Vicki Mullin filed a petition for compensation under the National
Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.2 (the “Vaccine
Act”). Petitioner alleges that she suffered a shoulder injury related to vaccine
administration (“SIRVA”) as a result of an influenza (“flu”) vaccine she received in her
right shoulder on November 11, 2020.3 Pet. at 1, ECF No. 1. The case was assigned to
the Special Processing Unit (“SPU”) of the Office of Special Masters.
1 Because this Ruling contains a reasoned explanation for the action taken in this case, it must be made
publicly accessible and will be posted on the United States Court of Federal Claims' website, and/or
at https://www.govinfo.gov/app/collection/uscourts/national/cofc, in accordance with the E-Government Act
of 2002. 44 U.S.C. § 3501 note (2018) (Federal Management and Promotion of Electronic Government
Services). This means the Ruling will be available to anyone with access to the internet. In accordance
with Vaccine Rule 18(b), Petitioner has 14 days to identify and move to redact medical or other information,
the disclosure of which would constitute an unwarranted invasion of privacy. If, upon review, I agree that
the identified material fits within this definition, I will redact such material from public access.
2 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C.
§ 300aa (2018).
3 The petition states that Petitioner also received a Pneumovax 23 vaccine in the same arm as the covered
flu vaccine. See Ex. 2 at 8-9.

Case 1:23-vv-00940-UNJ Document 24 Filed 08/20/24 Page 2 of 7
For the reasons discussed below, I find the flu vaccine alleged as causal was more
likely than not administered in Petitioner’s right shoulder.
I. Relevant Procedural History
Shortly after initiating her claim, Petitioner filed her affidavit, vaccination record
(failing to set forth an administration situs),4 medical records, and a statement of
completion. ECF Nos. 6, 8. This case was then activated and assigned to SPU in October
2023. ECF No. 9.
In February 2024, Respondent represented that he had some questions regarding
Petitioner’s vaccine administration record, namely that such records “do not indicate the
site of vaccination . . . .” Scheduling Order, ECF No. 13. Respondent noted that Petitioner
had tried to obtain a “better vaccine administration record” (Ex. 10), but the facility claimed
“they couldn’t produce anything else.” Id. at 1. Subsequently, in response to a subpoena
served upon Petitioner’s pharmacy in which the subject flu vaccination was administered,
the pharmacy stated that a search was completed for evidence of Petitioner’s November
11, 2020 record but “no records were found.” See Ex. 15 at 1; see also ECF Nos. 14-18.
Thus, prior to Respondent providing his position in this case, I find it helpful to issue the
instant finding regarding situs.
II. Issue
At issue is whether Petitioner received the vaccination alleged as causal in her
right arm. 42 C.F.R. § 100.3(a) XIV.B. (2017) (influenza vaccination).
III. Authority
Pursuant to Vaccine Act Section 13(a)(1)(A), a petitioner must prove, by a
preponderance of the evidence, the matters required in the petition by Vaccine Act
Section 11(c)(1). A special master must consider, but is not bound by, any diagnosis,
conclusion, judgment, test result, report, or summary concerning the nature, causation,
and aggravation of petitioner’s injury or illness that is contained in a medical record.
Section 13(b)(1). “Medical records, in general, warrant consideration as trustworthy
evidence. The records contain information supplied to or by health professionals to
facilitate diagnosis and treatment of medical conditions. With proper treatment hanging in
the balance, accuracy has an extra premium. These records are also generally
4 Petitioner’s vaccination record in fact does not explicitly state that the subject flu vaccine was administered
on November 11, 2020. Instead, it memorializes that an order for Petitioner’s flu vaccine was “filled” on
“11/6/20, 11:14 AM” – but with a “pickup date” of “11/11/20, 4:57 PM.” It thus appears that the record would
support a finding that Petitioner received the subject flu vaccine on November 11, 2020, as alleged.
2

Case 1:23-vv-00940-UNJ Document 24 Filed 08/20/24 Page 3 of 7
contemporaneous to the medical events.” Cucuras v. Sec’y of Health & Hum. Servs., 993
F.2d 1525, 1528 (Fed. Cir. 1993).
Accordingly, where medical records are clear, consistent, and complete, they
should be afforded substantial weight. Lowrie v. Sec’y of Health & Hum. Servs., No. 03-
1585V, 2005 WL 6117475, at *20 (Fed. Cl. Spec. Mstr. Dec. 12, 2005). However, this rule
does not always apply. In Lowrie, the special master wrote that “written records which
are, themselves, inconsistent, should be accorded less deference than those which are
internally consistent.” Lowrie, 2005 WL 6117475, at *19.
The United States Court of Federal Claims has recognized that “medical records
may be incomplete or inaccurate.” Camery v. Sec’y of Health & Hum. Servs., 42 Fed. Cl.
381, 391 (1998). The Court later outlined four possible explanations for inconsistencies
between contemporaneously created medical records and later testimony: (1) a person’s
failure to recount to the medical professional everything that happened during the relevant
time period; (2) the medical professional’s failure to document everything reported to her
or him; (3) a person’s faulty recollection of the events when presenting testimony; or (4)
a person’s purposeful recounting of symptoms that did not exist. La Londe v. Sec’y of
Health & Hum. Servs., 110 Fed. Cl. 184, 203-04 (2013), aff’d, 746 F.3d 1335 (Fed. Cir.
2014).
The Court has also said that medical records may be outweighed by testimony that
is given later in time that is “consistent, clear, cogent, and compelling.” Camery, 42 Fed.
Cl. at 391 (citing Blutstein v. Sec’y of Health & Hum. Servs., No. 90-2808, 1998 WL
408611, at *5 (Fed. Cl. Spec. Mstr. June 30, 1998)). The credibility of the individual
offering such testimony must also be determined. Andreu v. Sec’y of Health & Hum.
Servs., 569 F.3d 1367, 1379 (Fed. Cir. 2009); Bradley v. Sec’y of Health & Hum. Servs.,
991 F.2d 1570, 1575 (Fed. Cir. 1993).
The special master is obligated to fully consider and compare the medical records,
testimony, and all other “relevant and reliable evidence contained in the record.” La
Londe, 110 Fed. Cl. at 204 (citing § 12(d)(3); Vaccine Rule 8); see also Burns v. Sec’y of
Health & Hum. Servs., 3 F.3d 415, 417 (Fed. Cir. 1993) (holding that it is within the special
master’s discretion to determine whether to afford greater weight to medical records or to
other evidence, such as oral testimony surrounding the events in question that was given
at a later date, provided that such determination is rational).
3

Case 1:23-vv-00940-UNJ Document 24 Filed 08/20/24 Page 4 of 7
IV. Finding of Fact
The following finding of fact is based on a complete review of the record, including
the petition, all medical records, affidavits, and additional evidence filed.
• Ex. 3 ¶ 3, Petitioner’s affidavit, wherein she attests that she “received a flu
shot in [her] dominant right shoulder on November 11, 2020.” She states
that she started having pain in her right shoulder “immediately after
receiving the flu vaccine” and that the nurse administered the vaccine “very
high up in [her] shoulder.” Id. ¶ 5.
• Ex. 11 at 2, a reproduction of a text message Petitioner sent on November
12, 2020 (the day after the subject vaccination), at 7:18 AM. The text reads
“[she] got 2 shots yesterday in [her] arm and am having a reaction and have
been in so much pain all night and can not [sic] even lift [her] right arm!!”
Another text message states “[she] had flu and pneumonia shot [sic]
yesterday and pharmacist did both in [her] right arm!” Id. at 3. Such
messages, while they indeed provide context to Petitioner’s argument
regarding situs, are appropriately deserving of less weight as they are not
akin to a contemporaneous medical record.
• Ex. 4 at 222, a record from a phone call to Petitioner’s primary care
physician (“PCP”) on November 12, 2020, stating “[Petitioner] had both flu
and pneumonia shots in her dominant arm yesterday and now she cannot
use that arm at all . . . she states the pharmacist didn’t ask which was her
dominant arm and said that she could get both shots with no problem.”
Other than referring to her “dominant arm,” this record does not contain
complaints specific to the right shoulder.
• Ex. 5 at 11-12, memorializing that during her visits on November 16, 2020
(a telehealth follow-up with her rheumatologist for pre-existing lupus and
related bilateral hand pain) and February 4, 2021 (a PCP follow-up for
migraines, neck pain, and chest tightness) (Ex. 4 at 28-32), Petitioner did
not mention right shoulder complaints. While this fact does not impede
Petitioner’s ability to establish situs, I include it to highlight some of the
inconsistencies between the petition – wherein Petitioner alleges she made
right shoulder complaints during these visits – and the contemporaneous
medical records.
4

Case 1:23-vv-00940-UNJ Document 24 Filed 08/20/24 Page 5 of 7
• Ex. 5 at 8-10, a record from Petitioner’s March 15, 2021 rheumatology
follow-up stating that she “is complaining of pain in the right arm” and since
her last visit her “arthritis/condition is: Worse.” Id. at 8. The assessment
noted “arthralgia, unspecified joint.” Id. at 9. The record does not include a
connection between Petitioner’s right arm pain and the subject flu
vaccination. See id.
• Ex. 4 at 19-20, a record from Petitioner’s June 11, 2021 visit with her PCP
wherein her chief complaint was “shoulder problem right.” She complained
of “right shoulder pain with decreased [range of motion (“ROM”)]” and that
she “received a pneumonia and flu vaccine in the right arm in November
and has been having worsening pain since then.” Id. at 23. A physical
examination revealed “tenderness and limited ROM; right shoulder tender
to palpation at the [acromioclavicular (“AC”)] notch. Pain and decreased
ROM with adduction flexion and external rotation.” Id. Petitioner was
assessed with “pain in unspecified shoulder,” and physical therapy (“PT”),
an x-ray of the right shoulder, and meloxicam were recommended. Id. at 24.
• Ex. 4 at 15-18, a follow-up with Petitioner’s PCP for “right shoulder pain” on
September 24, 2021. The PCP noted that this pain “began after [Petitioner]
received a COVID-19 vaccine.”5 Id. at 18. Petitioner’s physical examination
was unchanged. Id. at 19. The PCP noted Petitioner had completed some
PT with her sister (a physical therapist), her meloxicam prescription was
increased, and an MRI of the right shoulder was ordered. Id.
• Ex. 6 at 16, a record from Petitioner’s October 6, 2021 MRI of the right
shoulder, showing moderate supraspinatus tendinosis with a partial
thickness tear involving the “mid to anterior fibers at the footprint involving
greater than 50% of the tendon thickness[;]” mild infraspinatus tendinosis
without a discrete tear; subacromial/subdeltoid bursitis; and type 2
acromion with mild anterior and lateral downsloping, “predispos[ing
Petitioner] to clinical impingement syndrome.”
• Ex. 7 at 48, a record from Petitioner’s October 18, 2021 initial PT evaluation
for pain in the right shoulder. Petitioner underwent seven PT sessions for
her right shoulder symptoms through November 12, 2021. Id. at 33-48.
5 It is not clear whether this entry regarding the COVID-19 vaccine was made in error. Petitioner should aim
to address or otherwise remedy this discrepancy.
5

Case 1:23-vv-00940-UNJ Document 24 Filed 08/20/24 Page 6 of 7
• Ex. 8 at 8, a record from an orthopedic evaluation on November 15, 2021,
wherein Petitioner presented with “dominant sided, right shoulder pain that
began one year ago with after [sic] her COVID vaccine injections.” The
impression included a “right shoulder high grade partial thickness tear
supraspinatus, SLAP lesion, [and] impingement.” Id. at 9. Arthroscopic
surgery was recommended for Petitioner’s right shoulder symptoms, which
she underwent in December 2021. See id. at 9, 12, 24-25. She thereafter
received subsequent treatment, including post-operative PT and a steroid
injection in the right shoulder in February 2022. Ex. 7 at 108-42; Ex. 8 at 45.
When such efforts were unsuccessful at treating her pain, Petitioner
underwent a second surgery of the right shoulder in August 2022, followed
by additional PT. Ex. 8 at 60-61; Ex. 7 at 144.
The above evidence preponderantly supports the conclusion that Petitioner’s
subject November 2020 vaccination was likely received in her right shoulder, as alleged.
The record of Petitioner’s November 12, 2020 call to her PCP, noting she received the
subject vaccination in her dominant arm (Ex. 4 at 222), is particularly persuasive. This
record is from only one day post-vaccination, and while it does not contain visit notes or
physical findings, it is the most contemporaneous record other than the vaccine
administration record itself that is silent as to site. Although this record does not clarify
which arm is Petitioner’s dominant, the record from Petitioner’s November 15, 2021
orthopedic visit (noting “dominant sided, right shoulder pain that began one year ago”)
provides context to this earlier record. When taken together, such evidence is sufficient
support for the alleged right arm situs.
I acknowledge that the vaccine administration record itself does not memorialize
the site of the administration of Petitioner’s flu vaccine. Ex. 2 at 8. However, all other
medical records and Petitioner’s affidavit support a finding that the covered flu vaccine
was administered in Petitioner’s right arm. Moreover, in addition to Petitioner’s self-
reports to treaters and her own statements in her affidavit, her medical records
consistently document diagnostic testing, physical therapy exercises, and treatment of
Petitioner’s right shoulder. To rule otherwise, the overall record would need to contain
more instances in which the counter situs was suggested or supported.
I also note that some of Petitioner’s medical records attribute her right shoulder
pain to her receipt of a non-covered COVID-19 vaccine. Ex. 4 at 18; Ex. 8 at 8. However,
when weighed against Petitioner’s other medical records, wherein she described pain
following flu and pneumonia vaccinations in the right arm (Ex. 4 at 23, 222), I find the
evidence regarding situs to favor Petitioner (albeit barely). Overall, such circumstances
produce, at worse, a “tie” in evidence that should be decided in Petitioner’s favor. Roberts
6

Case 1:23-vv-00940-UNJ Document 24 Filed 08/20/24 Page 7 of 7
v. Sec’y of Health & Hum. Servs., No. 09-427V, 2013 WL 5314698, at *10 (Fed. Cl. Spec.
Mstr. Aug. 29, 2013) (noting petitioners are afforded the benefit of close calls in the
Vaccine Program).
V. Scheduling Order
Respondent shall file, by no later than Friday, August 16, 2024, a status
report stating how he intends to proceed in this case. At a minimum, the status report
shall indicate whether he is willing to engage in tentative discussions regarding settlement
or proffer, is opposed to negotiating at this time, or whether he needs additional time to
determine his position. In the event Respondent wishes to file a Rule 4(c) report, he may
propose a date for filing it, but shall indicate his position on entering into negotiations
regardless of whether he wishes to file a Rule 4(c) Report.
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
7

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DOCUMENT 2: USCOURTS-cofc-1_23-vv-00940-1
Date issued/filed: 2024-10-22
Pages: 2
Docket text: PUBLIC ORDER/RULING (Originally filed: 09/20/2024) regarding 28 Ruling on Entitlement Signed by Chief Special Master Brian H. Corcoran. (nh) Service on parties made.
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Case 1:23-vv-00940-UNJ Document 31 Filed 10/22/24 Page 1 of 2
In the United States Court of Federal Claims
OFFICE OF SPECIAL MASTERS
No. 23-940V
VICKI MULLIN, Chief Special Master Corcoran
Petitioner, Filed: September 20, 2024
v.
SECRETARY OF HEALTH AND
HUMAN SERVICES,
Respondent.
Jimmy A. Zgheib, Zgheib Sayad, P.C., White Plains, NY, for Petitioner.
Ilana Sherry Greenberg, U.S. Department of Justice, Washington, DC, for Respondent.
RULING ON ENTITLEMENT1
On June 23, 2023, Vicki Mullin (“Petitioner”) filed a petition for compensation under
the National Vaccine Injury Compensation Program, 42 U.S.C. §300aa-10, et seq.2 (the
“Vaccine Act”). Petitioner alleges that she suffered from a shoulder injury related to
vaccine administration (“SIRVA”) as a result of receiving an influenza (“flu”) vaccination
on November 11, 2020. Pet., ECF No. 1. Petitioner further alleges that she suffered the
residual effects of her injury for more than six months. Id. The case was assigned to the
Special Processing Unit of the Office of Special Masters.
In light of my July 17, 2024 fact ruling finding Petitioner received the subject flu
vaccination in her right shoulder, as alleged, on September 18, 2024, Respondent filed
his Rule 4(c) report in which he concedes that Petitioner is entitled to compensation in
1 Because this Ruling contains a reasoned explanation for the action taken in this case, it must be made
publicly accessible and will be posted on the United States Court of Federal Claims' website, and/or
at https://www.govinfo.gov/app/collection/uscourts/national/cofc, in accordance with the E-Government Act
of 2002. 44 U.S.C. § 3501 note (2018) (Federal Management and Promotion of Electronic Government
Services). This means the Ruling will be available to anyone with access to the internet. In accordance
with Vaccine Rule 18(b), Petitioner has 14 days to identify and move to redact medical or other information,
the disclosure of which would constitute an unwarranted invasion of privacy. If, upon review, I agree that
the identified material fits within this definition, I will redact such material from public access.
2 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99-660, 100 Stat. 3755. Hereinafter, for ease
of citation, all section references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. §
300aa (2018).

Case 1:23-vv-00940-UNJ Document 31 Filed 10/22/24 Page 2 of 2
this case. Respondent’s Rule 4(c) Report at 2, ECF No. 25. Specifically, Respondent
indicated that “[P]etitioner suffered SIRVA as defined by the Vaccine Injury Table.” Id. at
5. Respondent does not dispute that Petitioner “has satisfied all legal prerequisites for
compensation under the Act.” Id. at 6.
In view of Respondent’s position and the evidence of record, I find that
Petitioner is entitled to compensation.
IT IS SO ORDERED.
s/Brian H. Corcoran
Brian H. Corcoran
Chief Special Master
2