Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Back pain, Cardiac stress test, Fatigue, Headache, Musculoskeletal pain
Clinical narrative: had slight headaches this morning; he thought he was going to vomit but it was just dry heaves; shoulder blades started getting sore; feels like he has gone through the ringer; keeps getting that tired feeling; back aches; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP), Program ID: (159558). The reporter is the patient.  A 69-year-old male patient received BNT162b2 (BNT162B2), on 12Apr2022 as dose 4 (booster), single (Lot number: FK8995) at the age of 69 years, in left arm for covid-19 immunisation. The patient's relevant medical history included: "Open heart surgery", start date: 2009, stop date: 2009; "Indigestion" (unspecified if ongoing); "sexual help" (unspecified if ongoing); "Heart disorder" (unspecified if ongoing); "required iron supplement" (unspecified if ongoing); "required folic acid" (unspecified if ongoing); "Metabolism support" (unspecified if ongoing); "keeps his blood thin" (unspecified if ongoing); "Cholesterol" (unspecified if ongoing); "Diabetes" (unspecified if ongoing); "Interchange of vaccine products" (unspecified if ongoing). Concomitant medication(s) included: OMEPRAZOLE taken for dyspepsia; METOPROLOL taken for cardiac disorder, start date: 2009 (ongoing); TADALAFIL taken for sexual dysfunction; FLUOXETINE HCL taken for cardiac disorder, start date: 2009 (ongoing); IRON SUPPLEMENT WITH VIT C & HERBS taken for mineral supplementation; LISINOPRIL (ongoing); FOLIC ACID GENERIC taken for vitamin supplementation (ongoing); NIACIN taken for metabolic disorder (ongoing); SIMVASTATIN taken for blood cholesterol abnormal (ongoing); BABY ASPIRIN taken for anticoagulant therapy (ongoing); JANUVIA taken for diabetes mellitus (ongoing); B12 [CYANOCOBALAMIN] (ongoing). Vaccination history included: moderna (Dose number: 1, Lot number: 013AZ1A, NDC, EXP: Unknown), administration date: 08Mar2021, when the patient was 68-year-old, for COVID-19 immunization, reaction(s): "No adverse effect"; moderna (Dose number: 2, Lot number: 025AZ1A (it could also be 025A21A, stating the Z could be a 2), NDC, EXP: Unknown), administration date: 05Apr2021, when the patient was 68-year-old, for COVID-19 immunization, reaction(s): "No adverse effect"; BNT162b2 (Dose number: 3, Lot number: FG3590, NDC, EXP: Unknown), administration date: 01Nov2021, when the patient was 68-year-old, for Covid-19 immunization, reaction(s): "No adverse effect". The following information was reported: TINNITUS (non-serious) with onset 12Apr2022, outcome "unknown", described as "feels like he has gone through the ringer"; MUSCULOSKELETAL PAIN (non-serious) with onset 12Apr2022, outcome "unknown", described as "shoulder blades started getting sore"; HEADACHE (non-serious) with onset 13Apr2022, outcome "unknown", described as "had slight headaches this morning"; RETCHING (non-serious) with onset 13Apr2022, outcome "unknown", described as "he thought he was going to vomit but it was just dry heaves"; BACK PAIN (non-serious) with onset Apr2022, outcome "unknown", described as "back aches"; FATIGUE (non-serious) with onset Apr2022, outcome "unknown", described as "keeps getting that tired feeling". Relevant laboratory tests and procedures are available in the appropriate section. Therapeutic measures were not taken as a result of musculoskeletal pain, headache, tinnitus, fatigue, retching. Therapeutic measures were taken as a result of back pain.  Additional information: Patient received the second Booster on the left arm up on the shoulder. Family Medical History Relevant to AE(s): His mother was diabetic and had heart trouble, also. All three brothers have heart problems and his older sister has so far, skated free and has had no heart problems. Concomitant medications included; OMEPRAZOLE which patient stated he takes it 30 minutes to an hour before he eats, if he has a little indigestion, he takes one and it stops it pretty well, dosage text: 20mg PRN; METOPROLOL patient has been on it ever since he had heart surgery, 50mg one daily; TADALAFIL patient has been on for about a year for sexual help, 5mg, once a day; FLUOXETINE HCl, patient has been taking since he had heart surgery and had been taking it all along, 40mg, once a day; IRON SUPPLEMENT when his arm goes down, they always put him on this off and on and stated that it has been maybe 3 years with this go around, 325mg usually one day for iron supplementation; LISINOPRIL, patient does not remember had been taking, probably about 3 or 4 years, 10mg, morning and evening, twice a day; FOLIC ACID 800 patient had been taking 2 years probably, 1,333 mcg once a day; NIACIN, 500mg daily for metabolism support; SIMVASTATIN He has been taking it since after the heart surgery, patient knows they gave him one medication for his cholesterol levels, his bad levels were low and good levels were high and they said to keep it that way, 40mg once at bedtime; B12 1,000 mcg; BABY ASPIRIN patient stated that it beats the 325 and stated they changed the protocol, 81mg once a day for keeping his blood thin; JANUVIA, patient had been taking probably about 3 years, maybe, 50mg one tablet a day. Caller stated he sees a cardiologist next month. He stated he passed his stress test 90 days post surgery. Caller stated one of the medications was making him anemic. They thought the problem was in his colon but, couldn't find anything then. Then, they found that one of the medications he was on had anemia as one of the side effects. That Monday morning, he went to see his doctor and when he went back Thursday, it had almost come up 2 points. He stated it was one pill and stated they put him on an older one that didn't cause anemia. Caller stated he does not remember the name of this medication that caused the anemia. He states that he has been retired since 2016, so it would have been 2014 or 2015. Caller stated that for this one (first booster), when they put the needle in, he felt it going in and they were good with the needle. Anatomical location of first 2 doses and the first booster dose was unknown. Patient goes in for fasting blood sugar every 6 months. There were no additional vaccines administered on same date of the Pfizer Suspect. Patient received no prior Vaccinations (within 4 weeks). No AE(s) following prior vaccinations. The reporter was a consumer calling to share his reaction he experienced after getting the second booster shot yesterday. Caller stated he was a nursing assistant. Reporter stated that the shoulder blades started getting sore and he had not had any reaction to the first shots. Clarified that it was between the shoulder blades. It was still sore somewhat but not like it was yesterday. This morning when he got up, he thought he was going to vomit but it was just dry heaves. He didn't have anything to come up because he hadn't eaten anything since last night. Clarified that this only occurred the one time, this morning. He had slight headaches this morning. Caller stated that he feels like he has gone through the ringer, like how a washing machine goes. Clarified he had that experienced last night and today. Caller stated when he got home, the pain was between the shoulder blades and then he went to bed. He worked on his laptop last night and then got up this morning, and just felt like he was run through the ringer and keeps getting that tired feeling. Treatment was reported as no, patient took some TYLENOL last night for the back ache, before he went to bed. Patient did not visit emergency room and physician's office.