Age: 77.0
Sex: M
Vaccine: COVID19
Symptoms: Arthralgia, Myalgia, Pain in extremity, Physiotherapy, X-ray
Clinical narrative: Aching arms/His upper arm and shoulder area, the soft tissue, just aches if he moves it a certain way and it hurts; His upper arm and shoulder area, the soft tissue, just aches if he moves it a certain way and it hurts; He heard a few complaints of muscle aches but usually resolved itself and his has not; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP). The reporter is the patient.  A 77-year-old male patient received BNT162b2 (BNT162B2), on 09Nov2021 as dose 3 (booster), single (Lot number: FG3522) at the age of 77 years, in arm for covid-19 immunisation. The patient's relevant medical history included: "Loss of muscle tone" (unspecified if ongoing), notes: He clarified that loss of muscle tone noticed 2-3 years ago, which was prior to getting the vaccine. There were no concomitant medications. Vaccination history included: BNT162b2 (1st dose 17Mar2021 left arm Lot EP6955 expiration is unknown), administration date: 17Mar2021, when the patient was 76-year-old, for COVID-19 Immunization; BNT162b2 (2nd dose 07Apr2021 at 11:30 am. Lot EW0150 expiration is unknown. Left arm he thinks.), administration date: 07Apr2021, when the patient was 76-year-old, for COVID-19 Immunization. The following information was reported: PAIN IN EXTREMITY (medically significant) with onset Nov2021, outcome "not recovered", described as "Aching arms/His upper arm and shoulder area, the soft tissue, just aches if he moves it a certain way and it hurts"; MYALGIA (medically significant) with onset Nov2021, outcome "not recovered", described as "He heard a few complaints of muscle aches but usually resolved itself and his has not"; ARTHRALGIA (medically significant) with onset Nov2021, outcome "not recovered", described as "His upper arm and shoulder area, the soft tissue, just aches if he moves it a certain way and it hurts". The patient underwent the following laboratory tests and procedures: Physiotherapy: Unknown results; X-ray: Ruled out arthritis and indicated soft tissue, notes: X-rays which ruled out arthritis and indicated soft tissue. Therapeutic measures were taken as a result of pain in extremity, arthralgia, myalgia.  Clinical course: Received call from consumer regarding Pfizer COVID 19 vaccine 2 of them and 1 booster. For last several months, he has had aching arms and loss of about 50% of physical ability. At first he thought age related because he is 78. He has loss of muscle tone because of age. Has been x-rayed and it is not arthritis. Had steroid shot and helped for a short while and then back to same. His upper arm and shoulder area, the soft tissue, just aches if he moves it a certain way (Things like reaching overhead, changing a lightbulb or digging up a root or shrub, any kind of motions like that) and it hurts. The only thing he can think of is COVID shot. He heard a few complaints of muscle aches but usually resolved itself and his has not. It has been close to a year since he had the booster. He then looked at his card and realized his booster was on 09Nov2021. Both events probably started 8 months ago but now thinks it was 12 months ago. The aching arms have stayed the same or a little worse. He has not gotten any relief since then except when he got a steroid shot and that lasted for a little while and then came back. During that phase of time he got a steroid shot and the doctor x-rayed him and said it was not arthritis and it was soft tissue. It was temporary relief from the steroid injection. Unknown name of steroid shot, lot and expiration or manufacturer. He stated he also received physical therapy treatments. He confirmed no emergency room or hospitalization required.