Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: Respiration abnormal, Slow speech, Swelling, Vaccination site discomfort
Clinical narrative: had the Covid arm issue; whole upper shoulder got red and swollen; getting red; spasm in left side of neck and jaw area; Breathing issues; Slight headache, what she describes as a pre-migraine on the left side; cognitive issues; slow speech; hypoglycemic; head was itching/started itching internally; tired; surges of energy, with euphoric and high feeling; surges of energy, with euphoric and high feeling; surges of energy, with euphoric and high feeling; major left elbow pain; her left palm got numb including her little finger and ring finger on her left hand; her left palm got numb including her little finger and ring finger on her left hand; shoulder starting hurting really bad, left top side of her shoulder; had an immediate pain on the right side of the breast bone straight through to the scapula; pain, to the middle suture and to the right side of the head all the way to the right jaw resulting in what she calls a classic migraine; swollen lymph nodes; sore throat; This is a spontaneous report from a contactable consumer (patient herself). A 58-years-old female patient received first dose of bnt162b2 (Solution injection; Batch/Lot Number: EW0186), via an unspecified route of administration, administered in Arm Left on 26Jul2021 at 09:00 (at the age of 58-years-old) as single dose for covid-19 immunisation. Medical history included reactivated Epstein Barr, chemical sensitivity, migraine, very low b12 and methylenetetrahydrofolate reductase gene mutation from 2012 and ongoing, this is a genetic mutation, she is C677T as there are different ones, she is the double mutation. The patient's concomitant medications were not reported. Caller reported that she got the first shot in 26Jul2021 and had lots of side effects after the first dose. After the first dose and within the first 5-10 minutes of receiving the first shot she had spasm in left side of neck and jaw area, this lasted several days, and it has resolved. Breathing issues that lasted 15-20 minutes and resolved. Slight headache, what she describes as a pre-migraine on the left side. She has a history of migraines. It then moved, the pain, to the middle suture and to the right side of the head all the way to the right jaw resulting in what she calls a classic migraine. This lasted about an hour and a half. She started having cognitive issues which was like a disconnect for her to get out what she is trying to get say, described as slow speech. Caller remarks she is hypoglycemic and has had before. This lasted about 5 minutes, she did better when drank something. She waited for 15 minutes the moved to waiting in the hall. At this time gradually her head was itching, this lasted about 10-15 minutes. She was at the facility she got the shot at for about an hour and a half just to make sure she was ok. In the evening she was tired, this lasted for a few days. It was explained during this time she also had surges of energy, with euphoric and high feeling and then she would get really tired. This lasted a couple days and went back and forth. Within 1 hour of getting the shot she started getting major left elbow pain and her left palm got numb including her little finger and ring finger on her left hand. This last 2-3 days. Her shoulder starting hurting really bad, left top side of her shoulder, not where the injection site was though. The next day her shoulder hurt more and that evening it started getting red. At the 2.5 day mark it started itching internally and the whole upper shoulder got red and swollen. She used ice and took a Tylenol. She would say at 2 days after getting the shot this got worse and was itching but she tried not to scratch. She called urgent care and on the 29th she went to the walking to make sure it was ok, confirmed she had the Covid arm issue, a mild case. even now she will get a twinge of itchiness but went away from the top but moved to the injection site. This lasted until at least 12Aug2021, so for 2.5 weeks or maybe 3 weeks. She remarks she also had swollen lymph nodes for brief time, this lasted 1.5 to 2 days. She had a sore throat at the same as swollen lymph nodes. Within the first 10 minutes, she had an immediate pain on the right side of the breastbone straight through to the scapula. This lasted awhile; it lasted about week. The events breathing issues, slight headache, what she describes as a pre-migraine on the left side, cognitive issues, hypoglycemic and head was itching/started itching internally was resolved on 26Jul2021. The outcome of the events spasm in left side of neck and jaw area, pain, to the middle suture and to the right side of the head all the way to the right jaw resulting in what she calls a classic migraine, tired, surges of energy, with euphoric and high feeling, shoulder starting hurting really bad, left top side of her shoulder, swollen lymph nodes and sore throat was resolved on unspecified date in 2021 while the outcome of major left elbow pain and her left palm got numb including her little finger and ring finger on her left hand was resolved on Jul2021. The outcome of the events had an immediate pain on the right side of the breast bone straight through to the scapula, had the Covid arm issue, getting red and whole upper shoulder got red and swollen was resolved in Aug2021.  Follow-up attempts are completed. No further information is expected.