Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Vaccination site pain
Clinical narrative: sinus issues; bad cold; muscle aches and sore injection site; dry mouth; sinus infection; A scratchy throat and cough; muscle aches and sore injection site; It is a little bit better but she can hardly lift her arm up halfway/could not hardly move her right arm; caller adds that there is a cough that foes with it; sinus pressure; arm was aching; This is a spontaneous report received from contactable consumer (patient). A 64-year-old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-119 VACCINE, Solution for injection, lot number: EW0167) via unknown route of administration on 13May2021 19:00 (at age of 64-year-old) as dose 1 single in right arm for COVID-19 immunization. Medical history included ongoing rheumatoid arthritis (diagnosed in 2001 or 2002). Concomitant medications included etanercept (ENBREL) 25 mg (sure-click self-injection) weekly for rheumatoid arthritis (has been on for 7 or 6 1/2 years), methotrexate at 10 mg, weekly to go along with the enbrel (been on for probably 18 years. she was diagnosed in 2001 or 2002 and started this a year after that). It was reported that her second dose was due for next week. muscle aches on 14May2021 and sore injection site: Caller adds she has a little bit of muscle aches, but early this morning, she woke up and could not hardly move her right arm in 2021. It was so sore at the injection site that that was at 4 o'clock in the shower, putting it in a hot shower, trying to get the muscle ache out of her arm. It was a little bit better but she can hardly lift her arm up halfway in 2021. She thought this was strange two weeks after the injection she was experiencing this issue. Caller adds it was kind of painful and she was kind of concerned. it was 7 pm she got the first dose on 13May2021 and she had worked and that was the first available. She did fine, just a muscle tinge or muscle ache started the next day within 24 hours but then she did not notice it until yesterday. She noticed her arm was aching a little bit in 2021. This morning, at 4 o'clock, she woke up in excruciating pain. It was like oh my gosh, what is wrong with her arm, and the whole upper arm where the injection site was was just so sore. She can push on where the injection site is and it is so sore there but the whole muscle it was injected into was awful. It wa very hard for her to raise her arm, she cannot even get it halfway up. Caller confirms the muscle aches are just in that arm, and it was her right arm. Caller adds she was left-handed, so she said to put it in her right one so that she can still use her left hand to write and stuff. Caller adds this concerns her because she did so good, she had a little bit of an ache but nothing and then, boom, like early last night and early this morning she rolled over in bed and it was just horrible, just horrible. She got up at 4 o'clock and got in a hot shower. She has taken Ibuprofen for pain. It does still just but she cannot, she had to lift her arm this morning with the other arm, it was scary. She was scared to get the second dose now. Caller adds she started having some sinus issues on 20May2021 and she does not know if that was related to it. She adds she has a bad cold or sinus on 20May2021, Thursday it started feeling bad. She did not put 2 and 2 together, It has gotten worse since Thursday. This morning, she ate something and took Ibuprofen and the muscle aches eased off a little bit. She got home at 12:30 and it was aching. Treatment: caller adds she just takes over the counter sinus medication, half a dose, because it makes her feel jumpy. It calls for 2 capsules and she does 1/4th of the dosage you are supposed to do. Caller adds it dries her up so bad, a dry mouth, like a sinus infection in 2021. She just does not like the way it makes her feel, it always dose that.  She has had sinus issues in the past but never this early in the year. Sinus medication: caller adds that she just bought some. It was Equate brand, Walmart brand. It was the Day and Night Sinus Maximum Strength, acetaminophen guaifenesin and then phenyl-HCI something. She was not sure what that was. Expiration states Mar2023 and there are lines beside the expiration that look like lot number but she cannot read it, maybe P124052. Sinus issues: caller adds that there is a cough that foes with it. A scratchy throat and cough in 2021, it was just sinus pressure that was in her sinuses. That was the only issue. The outcome of muscle ache was recovering, sinus disorder was not recovered, while for other events was unknown.  No follow-up attempts are needed. No further information is expected.