Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Blood cholesterol, Blood pressure measurement, Erythema, Inflammation, Middle insomnia
Clinical narrative: Rash of some sort and was pretty itchy; Arm swelled up; Arm was Pretty inflamed looking and pretty red; Arm was Pretty inflamed looking and pretty red; Arm wakes him up every night; Arm was sore/ pain in his arm; This is a spontaneous report from a contactable consumer (patient). A 67-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, formulation: solution for injection, lot number: EN6201, expiry date: unknown) via unspecified route of administration, administered in arm left on 27Feb2021 11:00 (age at vaccination 67-years-old) as DOSE 2, SINGLE for COVID-19 immunisation. The patient's medical history and concomitant medications were not reported. The patient took the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, formulation: solution for injection, lot number: EL3247, expiry date: unknown) via unspecified route of administration, administered in arm left on 06Feb2021 (age at vaccination 67-years-old) as DOSE 1, SINGLE for COVID-19 immunisation. The patient had no side effects after the first dose of the Covid-19 vaccine. The patient had flu shot in Jul2020 or Aug2020 and no other shots at all for 6 months other than the Covid-19 vaccine doses. After receiving the second dose of the Covid-19 vaccine, in Feb2021 the patient's arm was sore for a couple of day. His arm started hurting the second or third day after he received his second dose of the Covid-19 vaccine on 27Feb2021. He thought that his arm pain would last maybe 2 or 3 days but his arm hurts as much today as it did 2 months before. The patient never had a reaction to a shot before in his life, so it was new to him. The pain in his arm continued again and again for a long time. The patient could not even use his left arm to shampoo his hair, he had to use his right hand to shampoo his hair because his left arm hurt too badly to lift it above his head. The patient went to his doctor about a month or 3 to 4 weeks before and informed him that he has taken shots before and never had an allergic reaction. As of 28Apr2021, his arm still hurts as much now as it did 2 months before. About a month ago his doctor prescribed him muscle relaxers and pain pills for his arm pain. The muscle relaxers and pain pills did not help at all. Patient went to the emergency room on 27Apr2021 and had sonogram on his arm, they have looked at his arm for the better part of 15 to 20 minutes, maybe 30 minutes, and didn't find anything. The patient further reported that his left shoulder where he got his second dose of the Covid-19 vaccine to a little further than the bend in the elbow, his arm was pretty inflamed looking and pretty red in Apr2021. In Apr2021, it almost looked like he had a rash of some sort and was pretty itchy. In Apr2021, the patient arm swelled up in the last 2 to 3 weeks, probably not 1.5 but probably 25% larger than it's ever been. His left arm has never been bigger than his right arm before. He reported that he never gets sick and literally did not expect anything to happen on the Covid-19 vaccine either. Because of the swelling and rash broken out on his arm, the emergency room physician recommended to buy some Benadryl cream to rub on his arm. The physician also suggested to take something like allergy type tablets like a Benadryl or whatever it's called. The rash didn't appear until a week or two before and wasn't there a month before. It really started turning into a rash 2 weeks ago. It's like he's got poison ivy or something like that. He has real small bumps from where the crease of his elbow would be to about an inch down from his shoulder. The prescribed Benadryl has relieved some of the itching. The patient went to the emergency room where he received his Covid-19 vaccines. He read about the symptoms you could experience with a blood clot and everything listed were symptoms that he was showing. The symptoms for a blood clot listed redness, pain, swelling, possibly a little bit of rash. The patient was experiencing all of those symptoms. The pain in arm was probably about a 5 but it's to the point where he cannot sleep a full night. His arm wakes him up every night and it has been that way since the first of the month of Mar2021. Every day he kept expecting the arm pain to go away. He reported that his left arm looks like there wasn't a muscle because it is so puffy and his arm looks heavier. The arm swelling was noticeable and stated that if he took his shirt off, someone would be able to see the swelling in his left arm. The doctor recommended that he put hot compresses on his arm. The patient did that for about half an hour to 45 minutes last night. He did not get home until midnight from the emergency room, so he was up half the night applying the compress to his arm. The patient reported that his arm was more painful 2 weeks before, but last night it seemed to be a little better, last night he did take some Benadryl and some pain pills like Tylenol. The patient was getting older in life, he went to get his vaccines for shingles and pneumonia. The patient does not take any medications at all, his blood pressure was good, and his cholesterol is good. On 27Apr2021, the blood pressure was 110/65 and no clots found in ultrasound. The outcome of the events swollen arm, arm wakes him up every night, pain in arm was not recovered, outcome of the event Itchy rash, inflammation and redness were recovering.  No follow-up attempts are needed. No further information was expected.