Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Vaccination site rash, X-ray
Clinical narrative: muscle ache, especially the right side, the doctor thinks is nerve related; to cough hurts, to sneeze hurts, to turn from side to side in bed is almost impossible; progressively had pain in left shoulder blade and it has gotten worse; sore muscles; extreme muscle ache in left shoulder, more extreme in right upper side, it comes under her arm; a big terrible rash on her left arm; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of NEURITIS (muscle ache, especially the right side, the doctor thinks is nerve related), DISCOMFORT (to cough hurts, to sneeze hurts, to turn from side to side in bed is almost impossible), VACCINATION SITE RASH (a big terrible rash on her left arm), ARTHRALGIA (progressively had pain in left shoulder blade and it has gotten worse) and MYALGIA (sore muscles; extreme muscle ache in left shoulder, more extreme in right upper side, it comes under her arm) in an 82-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 030M20A and 032M20A) for COVID-19 vaccination.     The patient's past medical history included Chemotherapy and Radiation exposure. Concurrent medical conditions included Hypercholesterolemia, Hypertension, Osteoporosis and Lung cancer (almost in her 11th year with lung cancer, stable after chemotherapy and radiation). Concomitant products included ATORVASTATIN for Hypercholesterolemia, METOPROLOL for Hypertension, VITAMIN D [VITAMIN D NOS] for an unknown indication.   On 12-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 09-Mar-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On 09-Mar-2021, the patient experienced VACCINATION SITE RASH (a big terrible rash on her left arm) and MYALGIA (sore muscles; extreme muscle ache in left shoulder, more extreme in right upper side, it comes under her arm). On 16-Mar-2021, the patient experienced ARTHRALGIA (progressively had pain in left shoulder blade and it has gotten worse). On an unknown date, the patient experienced NEURITIS (muscle ache, especially the right side, the doctor thinks is nerve related) and DISCOMFORT (to cough hurts, to sneeze hurts, to turn from side to side in bed is almost impossible). The patient was treated with DEXAMETHASONE on 12-Apr-2021 for Pain, at a dose of 4 milligram and PARACETAMOL (TYLENOL) for Pain, at an unspecified dose and frequency. At the time of the report, NEURITIS (muscle ache, especially the right side, the doctor thinks is nerve related) and MYALGIA (sore muscles; extreme muscle ache in left shoulder, more extreme in right upper side, it comes under her arm) had not resolved and DISCOMFORT (to cough hurts, to sneeze hurts, to turn from side to side in bed is almost impossible), VACCINATION SITE RASH (a big terrible rash on her left arm) and ARTHRALGIA (progressively had pain in left shoulder blade and it has gotten worse) outcome was unknown.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): In April 2021, X-ray: did not show much of anything (normal) did not show much of anything. On an unknown date, Computerised tomogram: normal (normal) was ok.         It was reported that on 12-APR-2021, the patient's doctor ordered lab work to measure kidney function, but the results were not provided.   This case was linked to US-MODERNATX, INC.-MOD-2021-075763 (E2B Linked Report).   Most recent FOLLOW-UP information incorporated above includes: On 10-May-2021: Follow up was received on 10-MAY-2021. Patient's demographics- height and weight were added. Lab test- X-Ray result was updated. Outcome of events- myalgia and neuritis were updated to not recovered/resolved.; Sender's Comments:  US-MODERNATX, INC.-MOD-2021-075763:1st dose case