Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Eye disorder, Fall, Fatigue, Feeling abnormal, Feeling of body temperature change
Clinical narrative: felt achy; does not have the energy; sore inside my mouth; sound can hurt my ears; base of my left thumb hurts underneath the thumb where the thumb attaches to the hand; left hand cramp and tightness; Couldn't talk; could barely open her eyes / not be able to open her eyes; fell to the floor; food can taste extra, extra intense; ALT 71 (normal 7-52); sodium 131 (normal 136-144); MCH 34.20 (normal 26-34); MCV 100.30 (normal 80-98); i have a hard time seeing my computer screen; Headache; back pain; neck pain; shoulder pain; short term memory loss/memory problems; skin hurts; flustered; my body temperature, I can be freezing one minute and so hot; brain fog; can't find the words; I feel like I have ADD but on steroids; worked really hard to keep focus; not feeling well; itchy scalp that would be due to the Shingles; Muscle cramps; Muscle tightness; hard to walk; intense anxiety; big emotions, big anger, really really intense; big emotions, big anger, really really intense; exhausted/ fatigue; shingles; like the flu; staring into space; myoclonic jerks; hard time sleeping; stomach gas and bloating; stomach gas and bloating; This is a spontaneous report from a contactable consumer, the patient. A 64-year-old female patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE; Lot: EJ1686), via an unspecified route of administration in the left arm on 17Jan2021 (at the age of 64-years-old) as a single dose for COVID-19 immunization. Medical history included ongoing preglaucoma diagnosed 3-4 years ago, ongoing anxiety and depression her whole life, bronchitis at age 5, sinus infections, ongoing sinus allergy "stuff" and allergies (now the patient managed the allergies and did not get sinus infections), "vagititis" over 10 years ago and just essentially being dry, menopause a long time ago, both big toes have some fungus for probably 3 years (toenails look ugly, discolored and thick), ongoing arthritis and bone spurs to C5 and C6 to the area of the neck for which the patient did physical therapy (PT) for about 2 years, low on b-12 when she had shingles last time in 2016, "because I dont want to get Covid" (prophylaxis therapy), nearsighted and wore bifocals. Concomitant medications included bupropion for anxiety and depression for 5 years or longer, loratadine for allergies, COLECALCIFEROL (VITAMIN D3) for depression for 10 (maybe 20) years or more, vitamin b complex (SUPER B COMPLEX) from 2016 and ongoing for "low on B-12", cyanocobalamin (VITAMIN B-12) from 2016 for low B12, latanoprost for preglaucoma, clonazepam from 2012 and ongoing for anxiety, ESTROGENS CONJUGATED (PREMARIN) vaginal cream for "vagititis" and just essentially being dry, ascorbic acid (VITAMIN C) for "because I dont want to get Covid" and an unspecified complete multivitamin for women 50 and older from 2020 "so I wouldn't get Covid". The patient previously got the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE; Lot: EK5730) in the left arm on 30Dec2020 (at the age of 64-years-old) for COVID-19 immunization. Around the middle of Feb2021, the patient had a hard time sleeping. She still napped during the day most days. Also around middle of Feb2021, the patient noticed muscle jerks, which came and went. It had gotten worse. The doctor said these were myoclonic jerks. The worst was on 28Mar2021. In the middle of the night, the patient called her on call doctor and asked if it might be a seizure. The physician said it was not a seizure. The weekend of 06Mar2021, the patient started to not feel well. She did not sleep well that Friday or Saturday night. She could not access her memory (short term memory loss) as of 07Mar2021, was flustered and it was clear that something was off as the day progressed. On 07Mar2021, the patient felt her skin hurt, like when you had a fever and the skin hurts. This came and went. Around 07Mar2021, the patient felt intense anxiety which branched out into other intense emotional reactions (big emotions, big anger). On an unspecified date, the patient had a sore inside the mouth. Around 07Mar2021, the patient felt freezing one minute and so hot the next. On 07Mar2021 at 03:00, the patient experienced a bad headache. It was like her neck and her back and her shoulders had intense pain, cramping pain and she had to soak in Epsom salt. The severe headache happened twice, lasted about 2-3 days, moved from the right side of the head, or top of the head. She stayed home from work on 08Mar2021 and 09Mar2021. The patient was exhausted and felt achy, like the flu. She had an appointment with the doctor on 15Mar2021. She was not feeling well at this point. The patient developed shingles (one spot on the right-hand side on back of head) sometime after 15Mar2021 and was diagnosed on 22Mar2021. The patient had an itchy scalp due to the shingles and claimed shingles caused memory issues and brain fog, since 07Mar2021, (it seemed like she got "COVID brain"). The patient was prescribed Valacyclovir 1 mg oral tablet every 8 hours, 30 tablets, for the shingles on 22Mar2021. The open spot on the scalp crusted over by 01Apr2021 when the patient saw the physician again. The patient stated that shingles has lasting effects: brain fog, can't find the words, short-term memory problems have been coming and going since 07Mar2021, felt liked she has attention deficit disorder (ADD) on steroids, worked really hard to keep focus. This has worsened, maybe manifested more so in the last 3-4 weeks or so. Sometimes when she got anxious, her prefrontal cortex did not function well. After being diagnosed with shingles, the patient began to take propranolol 40 mg in Mar2021 as needed (patient takes 1/8 or part of 1/8 of a tablet, just biting off a tiny piece). Initially when she had shingles, she had "some finger in the light socket, fight or flight internally"; the propranolol helped with this. She took it very regularly in Mar2021 and had taken once a week at most the last 2-3 weeks. The patient also took "Brain Goo" as of 22Mar2021 which caused the stinkiest gas in the universe, and the patient was bloated, (reported as from Feb2021) depending on what she ate, and because of that, the following week, the patient took an anti-gas pill, simethicone.  She had muscle cramps (in the left upper thigh on the inside of the leg and outside of the leg) and tightness, in Mar2021, that made it hard to walk. The other area that tended to cramp up and cause problems were the arches, mostly the left arch. She reported it was probably 24Apr2021, she came downstairs in the afternoon or early evening and had such an intense cramp like a Charlie Horse and fell to the floor. Muscle cramps come and go, they shift around, it's in the left arch. It's not intensely sharp like it was that day.  Right now, her left arch has a knot. The patient began taking tizanidine around 08Apr2021 at 4mg 1 tablet 3 times a day for muscle cramps and tightness, which can get painful, and tizanidine helps relax that. The patient experienced fatigue due to which the patient cannot go to the grocery store by herself very easily as she gets wiped out. The patient had to hang on to the cart because she does not have the energy. She described fatigue and stamina as she had energy for a while and then she crashed. She reported she had to carry protein with her because she can literally crash. She reported her left leg gave out and she had to grab onto the counter and she almost went to the floor. On 24Apr2021, the patient couldn't talk and could barely open her eyes. It felt like her body was shutting down. She couldn't get herself up off the couch to go to the bedroom. This had not happened again. She told her physician about it who was sending her to a neurologist. On 02May2021, her left hand knotted up- had a cramped muscle and tightness. The base of her thumb hurt (underneath the thumb where the thumb attaches to the hand). The patient felt that sound can hurt her ears, which came and went. The patient had a hard time seeing the computer screen, which started between 01Apr2021- 08Apr2021. The patient mentioned this to the physician. She was nearsighted and wore bifocals and will take her glasses off to see the screen better). Food tasted extra intense as of 15Apr2021. On 06May2021, the patient was exhausted after being on the phone so long yesterday. On 06May2021, the patient reported staring off into space "like she could die and it wouldn't matter" and it felt like her brain was cramped up (like her brain was going to shut down). Caller reported that she has been staring off into space steadily, and it was kind of scary. Caller reported that the staring off into space has not occurred again like the first time where she felt like her brain was cramped. Caller reported that she feels like the staring off into space was connected in the same part of her brain that caused her to not be able to talk or open her eyes on the night of 24Apr2021. The patient reported that the staring off into space had continued on and off but not to that degree of intensity. She reported that the first time she stared off into space, she felt like she couldn't interrupt or stop staring off into space. Caller reported that she doesn't know how she stopped starting off into space the first time, but now when she stared off into space she can move her eyes. Caller reported that it felt like she had a cramp in her brain because she couldn't move her eyes. The staring into space was now better otherwise she would have gone to the emergency room. The patient underwent laboratory tests which included on 01Apr2021 which included: ALT 71 (normal 7-52), sodium 131 (normal 136-144), MCH 34.20 (normal 26-34), MCV 100.30 (normal 80-98), and on 02Apr2021, sodium 144, SARS-CoV-2 lgG Ab Antibody Test: reactive (detected value reactive, range non-reactive). The clinical outcome of staring into space, couldn't talk, "could barely open her eyes / not be able to open her eyes" was resolved on an unspecified date; herpes zoster and itchy scalp that would be due to the Shingles, sore inside my mouth was resolved on Mar2021; hard time sleeping, myoclonic jerks, not feeling well, "short term memory loss/memory problems", skin hurts, intense anxiety, "big emotions, big anger, really really intense",  "my body temperature, I can be freezing one minute and so hot ", headache, back pain, neck pain, shoulder pain, exhausted/fatigue, brain fog, " I feel like I have ADD but on steroids", worked really hard to keep focus, muscle tightness,  "base of my left thumb hurts underneath the thumb where the thumb attaches to the hand", left hand cramp and tightness, i have a hard time seeing my computer screen, food can taste extra, extra intense,  was not resolved; flustered, felt achy, like the flu, can't find the words, hard to walk, fell to the floor, does not have the energy,  sound can hurt my ears, ALT 71 (normal 7-52), sodium 131 (normal 136-144), MCH 34.20 (normal 26-34), MCV 100.30 (normal 80-98) was unknown; stomach gas and bloating, muscle cramps was resolving.  Follow-up attempts are needed. further information is expected