Age: 31.0
Sex: F
Vaccine: COVID19
Symptoms: Breast mass, Breast tenderness, Dizziness, Heart rate, Laboratory test
Clinical narrative: stomach cramping and pain; nausea; dizzy spells; painful; lymph nodes became very swollen and painful again; lumps in breasts; breast tenderness; lymph nodes became very swollen and painful again; Temperature: 99.9; This is a spontaneous report from a contactable consumer, the patient. This is the second of two reports. A 31-year-old non-pregnant female patient received the second dose of BNT162b2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE; Lot number: EW0182), via an intramuscular route of administration in the left arm/deltoid on 18May2021 at 10:59 (at the age of 31-year-old) as DOSE 2, SINGLE for COVID-19 immunisation. Medical history included possible autoimmune issue, heart block, heart pvcs, previous ovarian tumours removed, ongoing asthma, ongoing GERD, ongoing Allergies, ongoing Anxiety, ongoing Type 1 AV Block, Raynaud's phenomenon, Vitamin D deficiency, ongoing post-traumatic stress disorder, palpitation, Elevated blood pressure, Acne, removal of ovarian cyst, She had family history of hypertension and depression for father and mother, her father had diabetes mellitus, Former smoker (In 2014, she quit smoking, 0.25 packs per day), Disordered eating, hives and welts. The patient had known allergies to sulpha, penicillin, seasonal allergies, strawberries, arugala, dairy, meat products, spices, silver allergy. Concomitant medications included oral Montelukast sodium (SINGULAR) for allergies (strength 10 mg) , oral fexofenadine hydrochloride (ALLEGRA) for allergies, nasal fluticasone propionate (FLONASE) daily for allergies (strength 50 mcg ), vitamin d nos (MANUFACTURER UNKNOWN) and oral fish oil (MANUFACTURER UNKNOWN) as a supplement, albuterol sulphate (strength 90 mcg) as needed ; oral ascorbic acid taken for an unspecified indication, oral cholecalciferol taken for an unspecified indication daily, clindamycin; tretinoin taken for an unspecified indication topical, oral cyanocobalamin taken for an unspecified indication daily, oral diazepam taken for an unspecified indication daily, epinephrine taken for an unspecified indication as needed, oral fexofenadine taken for an unspecified indication, oral metoprolol tartrate taken for an unspecified indication daily, oral omeprazole taken for an unspecified indication daily, oral glucosamine taken for supplementation therapy, oral collagen taken for supplementation therapy ongoing, oral vitamin b nos taken for supplementation therapy. The patient previously received the first dose of BNT162b2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE; Lot number: EW0164) via Intramuscular route of administration in the left arm on 27Apr2021 at 10:59 (at the age of 31-years-old) as a single dose for COVID-19 immunisation and experienced painful lymph nodes in both breasts for 5 weeks plus fever 99- 101 on and off for 3 weeks after the first shot. Prior to the vaccination, the patient was not diagnosed with COVID-19. Since the vaccination, the patient had not been tested for COVID-19. The patient did not receive any other vaccines within four weeks prior to the vaccination. On 18May2021 at 11:00, the patient experienced stomach cramping and pain, nausea and dizzy spells. The events resulted in doctor or other healthcare professional office/clinic visit. On an unspecified date in 2021, She stated pain returned immediately after the second shot with the lymph nodes became very swollen and painful again. On an unspecified date in 2021, the patient temperature was 99.9. She thinks she has knots/lumps in breasts. She stated her breasts are 1-2 cup sizes larger which cannot be assessed. It was possible that she had a minor vaccine reaction. Patient was advised stay at the vaccination site for 30 minutes to be observed following administration. Advised patient that the incidence of anaphylaxis was extremely low. She got advice to continue her allergy medication and consider taking Pepcid if she develops any side effects and she take her EpiPen with her to the vaccination site. If she needs to use the Epi Pen, she should go immediately to the ER to be observed. On 03Jul2021, patient's blood pressure was 120/70 at Left brachial in sitting position, height was 5 feet 5-inch, Body Mass Index (BMI) was23.2, Temperature was 96.9 F L at Temporal Artery Scan and pulse rate was 118 (High), oxygen Sat b was 98 percent with Pulse Oximeter. Oxygen Deliver Method was room air and patient's weight were 139 lb 6 oz. On an unspecified date, lab test was performed and was normal. Positive appearance normal, both eyes and all related structures, no rashes or lesions noted, elasticity normal and turgor normal, patient alert, patient awake, patient oriented x3, gait normal, moves all extremities, no meningeal signs and no focal motor deficits. Appearance, Mental Status was grossly normal, Speech and Movement, Mood and Affect was normal, Attitude was cooperative thought Process and Thought Content was normal, insight and Judgment was good. Smoking risk assessment was performed. Therapeutic measures were taken as a result of the events. At the time of this report, the outcome of event temperature was resolved on an unspecified date in 2021, breast tenderness was not resolved, and other events were resolving at the time of this report.   Follow-up attempts are completed. No further information is expected.