Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: SARS-CoV-2 test, Sleep disorder
Clinical narrative: Also experienced extreme pain in right shoulder day after 2nd dose.; Felt lethargic; extremely weak; disoriented; Pain disrupts sleep caused from pain when moving in bed; Diagnosed with adhesive capsulitis (shoulder freeze); This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP). The reporter is the patient.  A 70-year-old male patient received BNT162b2 (BNT162B2), on 02Mar2021 as dose 2, single (Lot number: EN 6205) at the age of 70 years, in right arm for covid-19 immunisation. The patient's relevant medical history included: "Known allergies: Pencillin" (unspecified if ongoing); "A1C slightly elevated" (unspecified if ongoing), notes: A1C slightly elevated; "Thyroid cancer" (unspecified if ongoing); "Gall bladder removal" (unspecified if ongoing), notes: Gall bladder removal. Concomitant medication(s) included: ATORVASTATIN; PRILOSEC [OMEPRAZOLE]. Vaccination history included: BNT162b2 (Dose Number: 1, Batch/Lot No: EM 9810, Location of injection: Arm Left), administration date: 09Feb2021, when the patient was 70-year-old, for COVID-19 Immunization, reaction(s): "Extreme pain in left shoulder surfacing a few days after 1st injection", "Pain occurred when lifting left arm, reaching out or above head, placing arm behind back". The following information was reported: ARTHRALGIA (non-serious) with onset 03Mar2021 at 11:00, outcome "recovering", described as "Also experienced extreme pain in right shoulder day after 2nd dose."; PERIARTHRITIS (non-serious) with onset 03Mar2021 at 11:00, outcome "recovering", described as "Diagnosed with adhesive capsulitis (shoulder freeze)"; LETHARGY (non-serious) with onset 03Mar2021 at 11:00, outcome "recovering", described as "Felt lethargic"; SLEEP DISORDER (non-serious) with onset 03Mar2021 at 11:00, outcome "recovering", described as "Pain disrupts sleep caused from pain when moving in bed"; DISORIENTATION (non-serious) with onset 03Mar2021 at 11:00, outcome "recovering", described as "disoriented"; ASTHENIA (non-serious) with onset 03Mar2021 at 11:00, outcome "recovering", described as "extremely weak". The events "also experienced extreme pain in right shoulder day after 2nd dose.", "felt lethargic", "extremely weak", "disoriented", "pain disrupts sleep caused from pain when moving in bed" and "diagnosed with adhesive capsulitis (shoulder freeze)" required physician office visit. Relevant laboratory tests and procedures are available in the appropriate section. Therapeutic measures were taken as a result of arthralgia, lethargy, asthenia, disorientation, sleep disorder, periarthritis.  Extreme pain in left shoulder surfacing a few days after 1st injection that gradually subsided after a few weeks. Pain occurred when lifting left arm, reaching out or above head, placing arm behind back. Also experienced extreme pain in right shoulder day after 2nd dose. Felt lethargic, extremely weak, disoriented. Took a nap for about one hour and felt a little better. Pain disrupts sleep caused from pain when moving in bed. Difficulty lifting, reaching out and to the side. Went to Orthopedist and was diagnosed with adhesive capsulitis (shoulder freeze). Physician administered cortisone and provided stretching exercises. Worked out ok for a couple weeks and then slowly began to return to the same level as before the cortisone injection. Currently working with physical therapist to loosen encapsulation with minimal improvement. Prior to vaccination, was the patient did not diagnosed with COVID-19. Patient did not receive any other vaccines within 4 weeks prior to the COVID vaccine.