Perl v. Secretary of Health and Human Services, 15-1477

Petitioner Diane C. Perl filed a Vaccine Act claim alleging left-shoulder injury (SIRVA/adhesive capsulitis) after an influenza vaccination on October 9, 2013.
Medical records show petitioner received both an influenza and a pneumococcal vaccine that day, but the immunization record did not specify which arm received which vaccine.
Petitioner submitted a sworn affidavit stating the flu vaccine was given in her left shoulder and the pneumococcal vaccine in her right, and reported immediate and severe left-shoulder pain thereafter.
Contemporaneous medical records consistently note onset of left-shoulder symptoms beginning after the October 9, 2013 flu shot and document objective findings (x‑ray, MRIs, ultrasound) and treatment for left-shoulder pathology.
Respondent asked the court to decide whether petitioner proved by a preponderance of the evidence that a covered vaccine was administered in her left arm; the special master found the evidence supported that finding.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether petitioner proved by a preponderance that the influenza vaccine on Oct. 9, 2013 was administered to her left arm	Perl: affidavit + consistent reports to treating providers that left-shoulder pain began after the flu shot; objective left-shoulder findings support causally related injury	HHS: immunization record is silent as to arm location for each vaccine and cannot confirm which arm received the flu shot	Held: Preponderant evidence shows petitioner received the flu vaccine in her left shoulder (petitioner’s affidavit and consistent contemporaneous medical records credited)

Burns v. Secretary of Health & Human Services, 3 F.3d 415 (Fed. Cir. 1993) (special master weighs testimony and medical records when resolving factual disputes)
Cucuras v. Secretary of Health & Human Services, 993 F.2d 1525 (Fed. Cir. 1993) (contemporaneous medical records are presumed accurate)