Age: 80.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Cough, Discomfort, Laboratory test abnormal, Malaise, Muscular weakness
Clinical narrative: currently has Covid; currently has Covid; 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.  An 81-year-old female patient received BNT162b2 (BNT162B2), on 22Mar2021 as dose 1, single (Batch/Lot number: unknown) intramuscular, on 12Apr2021 as dose 2, single (Batch/Lot number: unknown) intramuscular, on 22Oct2021 as dose 3 (booster), single (Batch/Lot number: unknown) intramuscular and on 12Apr2022 as dose 4 (booster), single (Batch/Lot number: unknown) at the age of 80 years for covid-19 immunisation. The patient's relevant medical history included: "heart conditions" (unspecified if ongoing); "kidney issues" (unspecified if ongoing), notes: level 3 kidney issues and actually now they're level 4; "diabetes Type II" (unspecified if ongoing); "cholesterol" (unspecified if ongoing); "aortic stenosis" (unspecified if ongoing); "restless legs" (unspecified if ongoing); "diabetes" (unspecified if ongoing); "sugar" (unspecified if ongoing). Concomitant medication(s) included: FLU VACCINE VII taken for immunisation as dose number unknown, single; ATORVASTATIN taken for blood cholesterol abnormal; AZITHROMYCIN; CLONIDINE; GLIMEPIRIDE taken for blood glucose abnormal; DULOXETINE taken for restless legs syndrome; HYDRALAZINE; LEVOTHYROXINE; OMEPRAZOLE; PRAMIPEXOLE; RYBELSUS taken for diabetes mellitus; TORSEMIDE; VALSARTAN; VITAMIN D3. Past drug history included: Hemoglobin shots for anemic. The following information was reported: DRUG INEFFECTIVE (medically significant), COVID-19 (medically significant), outcome "unknown" and all described as "currently has Covid". The patient underwent the following laboratory tests and procedures: Blood cholesterol: 167, notes: Caller said was 167; Blood glucose fluctuation: Unknown results; Blood test: numbers were low, notes: she is getting bloodwork done; Body temperature: 99.2 Fahrenheit; 98.6 Fahrenheit; currently has a low grade temperature; Ultrasound bladder: numbers were low; Ultrasound kidney: numbers were low; Urine analysis: numbers were low. Therapeutic measures were taken as a result of drug ineffective, covid-19.  Clinical course: Caller, female, aged 81, currently had Covid, and has a past medical history of a heart conditions, level 3 kidney issues and actually now they're level 4, diabetes Type II, and she is under pressure to take the Paxlovid from her husband and daughter in law. No one has prescribed it yet. She did previously had the Pfizer BioNTech Covid 19 vaccine and never had any problems. She's dealt with Pfizer before and she likes them. She's also very anemic and has to get a hemoglobin shot every three weeks. She's in bad shape right now, she feels like she was hit in the head by a train. She reports she is having difficulty getting out of her chair, she's in the recliner, she can't pronounce her meds so she has a list for the doctor. She was unable to find her list so she just read off of her prescription bottles. She was also on antibiotics for bronchitis with a nasal drip and Covid is affecting her sinuses. Her kidneys used to be classified as a level 3 but now its level 4. She's getting some testing done and should hear back on the 14th. Caller was currently taking atorvastatin for cholesterol. She used to have aortic stenosis, so she is getting bloodwork done to see if they need to have surgery to empty it out. She is also taking the antibiotic azithromycin but only 6 tablets, one a day. Product: Paxlovid. Caller had some questions about Paxlovid and she said she had the Covid-19 Biontech vaccines and agent said doing a lack of effect for Covid. The caller confirmed the details provided by the transfer agent. Caller was coughing on the phone. caller said she had all of the vaccines. Caller said on the third day and her husband had for 5 days and 6 and currently has a low grade temperature and hers is 99.2 and nothing yesterday. Caller said is usually 98.6. Caller said computer and has more concerns and pressure and is terrible and taking her freedom. Caller said she called her heart doctor and is expecting a call back and she has an Oncologist and she is very very anemic and gets hemoglobin shots every 3 weeks and kidney does not get enough blood and caller said hemoglobin shots starts with an A and she is unsure how to spell and causes kidney to provide healthy cells and her hemoglobin goes up and and she is sure goes down too. She had called Pfizer before a long time ago and Pfizer was very helpful. Event date: Caller confirmed got Covid 3 days ago. Caller said she had the flu shot. Caller said she did not really want to get the vaccines due to health issues and nobody listed to her and lost almost all of her hair and not sure if that is a side effect. Caller said she is not going by what they want her to do and it is not their body and her and her Doctor knows. Caller confirmed she had received 4 total Covid-19 vaccines and thinks she will get another. Treatment: Not yet just pills and caller said Doctor changed her cholesterol and she has a test on the 14th and her carotid artery and she has aortic stenosis and that is what she was diagnosed with. Caller said was 167 and was not really bad and Doctor wanted stronger cholesterol medication before the test. She has been taking for a month or so. Caller said she is a little feeble on her feet. Caller said it feels sick like a head cold and they gave her azithromycin and she is able to get mucus up and said was a dry tickle cough and helped and she is drinking hot tea with lemon. Caller said they say its all dry. Caller said not concerning medication. She had a kidney and bladder ultrasound and had a urinalyses and blood work and she heard her report and the Nurse called yesterday and her numbers were low. No Prior Vaccinations (within 4 weeks). For Thromboembolic Events with Thrombocytopenia Include specific relevant test above. Caller got Covid 3 days ago and has received 4 Covid-19 vaccines. Manufacturer, NDC, Lot, and expiration are unknown for all Covid-19 vaccines. Doctor changed her cholesterol medication atorvastatin and she has a test on the 14th and her carotid artery and she has aortic stenosis and that is what she was diagnosed with. Caller said was 167 and was not really bad and Doctor wanted stronger cholesterol medication before the test.  The information on the batch/lot number for BNT162b2 has been requested and will be submitted if and when received.