Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Back pain, Blood pressure measurement, Blood test, Bone scan, Echocardiogram
Clinical narrative: eyes are a little swollen on top; Back pain/ soreness started in her thighs and is in her lower back; pain; Tiredness/exhausted; soreness in her arm/soreness started in her thighs; Spinal pain; She is wondering if the shot exacerbated a flare up, might be it is fibromyalgia,; This is a spontaneous report from a contactable consumer (patient).  A 64-year-old female patient received 0.3 mL of BNT162B2 (Batch/Lot Number: ER8727; Expiration Date: 31Jul2021), via an unspecified route of administration, administered in Left arm on 22Mar2021 11:30 (at the age of 64-year-old) as dose 1, single for COVID-19 immunization. Medical history included, she had 5 pneumonias and mitral leakage in the past. She was allergic to Penicillin shots, this happened 20-25 years ago, where she got a rash and had trouble breathing and they kept her in the hospital to observe her. Also had a Sulfa allergy that was about 11 years ago in 2000 and a Morphine allergy where she got a rash and hives and that started about 15 years ago. They gave it to her for a Fibromyalgia flare up. Her thyroid was removed. She has High cholesterol, anxiety, Fibromyalgia, muscle spasms, pain from herniated disc, arthritis in her hip, and muscle, leg, and bone pain. she must put her glasses on to read. Concomitant medications included simvastatin for high cholesterol increased from 16Mar2021; levothyroxine started taking 11 years ago, for thyroid removed, zolpidem tartrate (AMBIEN) to help her sleep, from an unspecified date, she was off it and went back on in Jan2021. states she tried to quit taking it but with her schedule it got tougher, and she had to start it again; lorazepam started taking about 1 year ago, when she has anxiety, she takes it and haven't had it yet for PTSD, tizanidine started taking 2 years ago, for fibromyalgia and muscle spasms, and paracetamol (TYLENOL) taken for pain from herniated disc, arthritis in her hip, and fibromyalgia, muscle, leg, and bone pain. On 22Mar2021, 12 hours after the vaccination, patient had soreness on her arm. On 23Mar2021 she started to have tiredness and it was not too bad. But it started to get bad on 24Mar2021 around 4-5pm and even the spinal pain too. On the same day night, her soreness in arm went away, which did not last even a day and a half. Patient stated that she took some Tylenol. she saw her doctor on 24Mar2021 and had a bone density scan done, result was normal and had blood work done.  And on 25Mar2021, in the morning when she woke up at 8am and saw her in the mirror, she found little swelling above her eyes, where they are not swollen shut.  Also, reported as she was exhausted and went to bed.  Also, patient had experienced the soreness, that started in her thighs and then her lower back and then spine. Her back pain was more like spinal pain, where she has to move around because it hurts and cannot sit down too long. Also, as it was moving around and was mostly in her spine, she stayed in bed and was more tired. It was also could found in her legs. She confirmed her breathing was ok. At the time of report, the tiredness is worse and still has spinal pain. It was confirmed that she had no headache, fever, or chills.  She has a pain management doctor, and she would have to call and check for spinal pain. She is really tired and as her spine hurts, she hasn't been out of bed to get the address for her doctor to provide.  Patient was wondering what she should do, where she does not want to go to Urgent Care.  She commented that she deals her pain with humor. She wonders if it is affecting her memory. She is wondering if the shot exacerbated a flare up, might be it is fibromyalgia, where her body reacting to it now. Patient had been drinking liquid because she was told to boost her liquids and she is not sure if that caused the swelling in her eyes, the puffiness.  She had been drinking a lot of water and she usually doesn't. On 25Mar2021, she checked her vitals, and they were fine. Her blood pressure was 110/79 and heart rate was good. As doctor knows she had Fibromyalgia, patient's blood work has done and her triglycerides and cholesterol were a little high, that her heart, liver, and kidneys and her thyroid levels were all ok. Stated her echo has done. She mentioned that she took Tylenol, later clarified as Tylenol 8hr Arthritis and it does not do anything.  She does not know if she is having a flare-up. Usually it works for her back/spine pain. But now it is not working right now. The outcome of the events fatigue and spinal pain was not recovered and of other events was unknown.   No follow-up attempts are needed. No further information is expected.