Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Body temperature, Body temperature increased, Chills, Erythema, Fatigue
Clinical narrative: headache; fatigue; pain at the site; pain at the site, swelling; chills; lethargic; temperature and it was holding steady at 99 degrees; her arm had gotten red and became very hot; her arm had gotten red and became very hot; This is a spontaneous report from a contactable Nurse (Patient herself). A 79-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE; Solution for injection), on 28Jan2021 at 09:15 (Batch/Lot Number: EL1283) (at the age of 79-year-old) as first dose intramuscular administered in arm right unknown dose, single for covid-19 immunisation. Medical history included ongoing Gastric anomalies, ongoing Allergies, breast cancer (also took cancer medication for 5 years but hasn't had that in 2 years), she had 2 implants (ongoing), but she hasn't had any radiation or chemotherapy in the last 2 years. She has arthritis down her spine and a couple other things wrong with her. She states it magnified those conditions and it stayed that way for a while. Her historical vaccine reported Flu in Sep2020. Ongoing concomitant medication included patient states she does have allergies and she does take daily medication for it. She also has a nasal medication, Montelukast and she was also on an oral tablet every day also takes dexlansoprazole (DEXILANT) which was a very powerful antacid for her gastric anomalies. She wasn't supposed to take it but for only 3 months but she has continued to take it for 5-10 years, more like 10 years and no one has stopped her. She states "Patient had a headache, fatigue, pain at the site, swelling but no lymphadenopathy after receiving her first dose. She had cancer in the past but clear now. Patient mentioned she got the first dose on 28Jan2021 and scheduled for her second dose 23Feb2021. Caller wants to know the side effects expected with the second dose. Patient received the first COVID-19 vaccine on 28Jan2021 at 9:15am. Around 2am or 3am the following morning (29Jan2021), her arm had gotten red and became very hot. It became really quite swollen. She couldn't move without it hurting. She took Tylenol without any advice from a doctor, she just took it herself. The Tylenol relieved some of the pain, but not all of it. Patient verifies the Tylenol is not handy when probed for NDC/UPC, Lot number or expiration date. She also started to experience chills but she never took her temperature. So at this point all of this was within 2 days after two 24 hour periods. Patient states on the 3rd day, everything seemed to lighten up and started to back off a bit. She took her temperature on the 3rd day and it was holding steady at 99 degrees. She didn't feel that any of this was earth shattering. She was taking more Tylenol and it relieved some symptoms. The Tylenol did help. By the fourth day, she was almost normal. She was so lethargic. She became extremely lazy and was laying around the TV. She states its all COVID's fault. She continued to have the magnification of her pre-existing conditions. Patient mentions her weight may be a little more than provided. She has been eating ice cream. Patient confirms at this point, she has recovered to her normal self, eating ice cream watching TV and playing with the puppies. The caller confirms the symptoms started letting up and she has recovered. Patient states she had some ablations on her back and muscle spasms. Her muscle spasms are pretty mellow and she hasn't had any treatments in a year and a half. Outcome of the event pain at the site was recovering and all other events was unknown. Events, redness in arm, arm became very hot and swollen, Chills and Lethargic was reported as related.  Follow-up attempts are completed. No further information is expected.