Age: 65.0
Sex: M
Vaccine: COVID19
Symptoms: Condition aggravated, Headache, Neck pain, Pain in extremity
Clinical narrative: right arm was so sore he couldn't  brush his hair; I am having severe neck pain/ Really at the neck and back of neck. and lowest part of back of the head.; I am having severe neck pain/Really at the neck and back of neck. and lowest part of back of the head.; it feels like it's getting worse/he back of his head on the right side was reported as worsened.; This is a spontaneous report received from a contactable reporter(s) (Consumer or other non-HCP) from medical information team. The reporter is the patient.  A 65-year-old male patient received bnt162b2 (BNT162B2), administered in arm right, administration date 08Apr2021 09:30 (Lot number: EP7533, Expiration Date: Jul2021) at the age of 65 years as dose 2, single for covid-19 immunisation. Relevant medical history included: "Heart Surgery" (unspecified if ongoing), notes: verbatim: Heart Surgery 1.75 years ago, valve repair open heart surgery to repair 2 valves. There were no concomitant medications. Vaccination history included: Bnt162b2 (Lot number: EP7533, Dose Number: 1, Anatomical site: Left Arm, Expiry Date: JUN2021), administration date: 18Mar2021, when the patient was 65 years old, for COVID-19 immunization, reaction(s): "little soreness in his left arm and upper back/neck", "little soreness in his left arm and upper back/neck". The following information was reported: PAIN IN EXTREMITY (non-serious) with onset Apr2021, outcome "recovered" (Apr2021), described as "right arm was so sore he couldn't brush his hair"; NECK PAIN (non-serious) with onset Apr2021, outcome "recovered" (Apr2021), described as "I am having severe neck pain/ Really at the neck and back of neck. and lowest part of back of the head."; HEADACHE (non-serious) with onset Apr2021, outcome "not recovered", described as "I am having severe neck pain/Really at the neck and back of neck. and lowest part of back of the head."; CONDITION AGGRAVATED (non-serious) with onset Apr2021, outcome "not recovered", described as "it feels like it's getting worse/he back of his head on the right side was reported as worsened.". Therapeutic measures were taken as a result of pain in extremity, neck pain, headache, condition aggravated.   Additional information: It was reported that reporter called for side effects, I filed a report. I am having severe neck pain from the vaccine, it's been 4 weeks, is there anything I can do for this, it feels like it's getting worse?" Is this common? that we are seeing a bit of?  Is there anything I can do? To make it go away.  What about heart?  Second dose on 08Apr2021. Caller states, "I didn't have anything in my left arm at first, nothing at first, a week later, arm and neck pain and week later, it went away.  The next time I got it in the right arm. I was wondering if it could be heart related so I did it in right arm.  At first, I had very minimal arm pain, it's getting worse, I had severe arm pain, that is fine now, it's feel it's getting worse and it has settled in to the back of the neck and right side and in the shoulder. Really at the neck and back of neck. and lowest part of back of the head. Response: Spoke from attached CONS  document. Spoke from attached VR Consumer document: Beyond information provided regarding CDC's recommendation for pain relievers, Pfizer does not provide any recommendations regarding the management or treatment of potential adverse events/reactions/symptoms that a patient /consumer may experience.  Your doctor/healthcare provider is in the best position to advise you about the appropriate action to take as your doctor/healthcare provider is most familiar with your medical condition, clinical history, how your treatment has been conducted and any relevant information to your specific case. Upon Follow up Additional Context: Caller is calling about the Pfizer Vaccine, verified Pfizer Covid Vaccine. Caller states he is calling to see if he can get some help with it. Caller states he has had both vaccines and after the first one he had a little soreness in his left arm and upper back/neck until about a week later. Caller states he switched to his right for the next time in case that happened again. Caller states the first week or two there was not much of anything, but after 2 weeks his right arm was so sore, he couldn't brush his hair and it still hasn't gone away. Caller clarifies, right now, the pain is not in the arm at all, but the pain is in his neck and the back of his head on the right side. Caller states both times the pain has been on the side that he got the shot. States he currently has no issues in the arms, but he has severe neck pain. Caller states he is calling to see if there is something that he can do for it. Caller asks, is this something that has been reported before? PCP: Declines; hasn't gone to see him for this. First Dose Left Arm Soreness AE: clarifies it started at least a week after the vaccine and it lasted for another week to 10 days and then it was done. States it was the arm and the back of the head/neck area on the left side. Exact dates unknown. Caller states he had heart surgery a year and a half ago, and the pain in the left arm was giving him mixed signals as to whether it was from the vaccine or his heart, so he decided he was going to go to the other side for the second shot. States he is pretty good with pain, and he didn't take any Tylenol with the first shot and then it went away. States he switched arms, so he didn't think it was his heart. Second Dose Right Arm Pain AE: States it was more the second time and he wasn't able to brush his hair. Caller states there was nothing immediate and he had no side effects at first and this came on later and continued until 4 weeks after that vaccine. States it started a week or two weeks after the vaccine. Exact dates unknown. Neck and Back of the Head Pain on the Right: Caller states it started 2 weeks after the injection and it has gotten worse. Exact dates unknown. Treatment: Tylenol.  Follow up attempts are completed. No further information is expected.