Age: 31.0
Sex: F
Vaccine: COVID19
Symptoms: Blood creatine phosphokinase, Blood test, Echocardiogram, Electrocardiogram, Pain in extremity
Clinical narrative: I have no issues with the first shot- other than soreness in my right arm; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP). The reporter is the patient.  A 31 year-old female patient (not pregnant) received bnt162b2 (COVID19 Vaccine- Solution for injection), administered in arm right, administration date 01Sep2021 15:00 (Lot number: FD0809) at the age of 31 years as dose 1, single for covid-19 immunisation. Relevant medical history included: "chest pains", start date: 23Sep2021 (ongoing); "upper back pain", start date: 23Sep2021 (ongoing). Concomitant medication(s) included: IBUPROFEN taken for pain, inflammation, start date: 04Oct2021, stop date: 18Oct2021; NAPROXEN taken for pain, start date: 27Oct2021 (ongoing); FAMOTIDINE taken for gastrooesophageal reflux disease, start date: 27Oct2021 (ongoing); OMEPRAZOLE taken for abdominal discomfort, start date: 27Oct2021 (ongoing); DAILY VITAMINS; PROBIOTICS. The following information was reported: PAIN IN EXTREMITY (non-serious) with onset 2021, outcome "unknown", described as "I have no issues with the first shot- other than soreness in my right arm". Relevant laboratory tests and procedures are available in the appropriate section. Additional information: Narrative case summary: Patient received second dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, Formulation: Solution for injection, lot number: FD0809), via an unspecified route of administration, administered in arm right on 22Sep2021 15:00 (at the age of 31-year-old) as Dose 2, Single for COVID-19 immunization. The patient medical history was reported as none including no known allergies. The patients concomitant medications included daily vitamins, probiotics, birth control medications received within 2 weeks of vaccination. Historical vaccination included the patient had previously received the first dose of bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, Formulation:Solution for injection, lot number: FD0809), via an unspecified route of administration, administered in arm right on 01Sep2021 15:00 (at the age of 31-year-old) as Dose 1,Single for COVID-19 immunization and experienced soreness in her right arm.The patient did not receive any other vaccines within 4 weeks prior to the COVID 19 vaccine. The patient had not been diagnosed with COVID-19 prior to vaccination and had been tested for Covid-19 since the vaccination. On 24Sep2021, the patient experienced body aches and fatigue; Eventually the aches were in her chest - both sides, aches in other parts of her body went away but aches in her chest did not. She started to have chest tightness, upper back discomfort (that would worsen when she laid on her back or sat back), heart palpitations and dull aches on the left side of her chest and sometimes in her left arm. On 01Oct2021, the patient went to urgent care and the EKG was normal. They prescribed a low dosage of pain med and muscle relaxers toradal but it didn't help. She finally went to see a cardiologist yesterday. On 04Oct2021 (Monday) because she considered she developed a heart issue, echo done & heart looked fine and strong, but they have no idea why she still have adverse aches in her chest area. The heart doctor kept her on some strong ibuprofen (IBUPROFEN, strength: 800 mg) for pain, inflammation and steroids and started feeling better by Thursday. The doctor felt like this was temporary and it was just prolonged autoimmune reactions from the shot. The patient hoped he was right. On 07Nov2021 the patients heart palpitations stopped (as well as caffeine). On 11Oct2021 the doctor told her to stay on ibuprofen as needed or seen herself off. She did another EKG - looked fine. The patient had a few bad days, but overall, it did seem to be slowly improving. She started to do muscle stretches. heating pad and bath with Epsom. She even took 3 turmeric pills dally, omega 3, a folic acid. On 22Oct2021- reduced medicines to 200 mg felt just fine. She stopped turmeric & other supplements earlier in the week for a break Saturday. Felt fine Sunday the 24Oct2021 she forgot to take medicine all together until that even, but she was okay. On 25Oct2021 (Monday)- Felt achy around 11:00 even though she took med that morning and around 13:00. These aches and upper back pain persist off and on all day. Around 19:00 she took 800 mg. On 26Oct2021 (Tuesday)- 800mg Ibuprofen and omega 3 and folic acid. Did some aches. been laying on heating pad. Aches here and there but evening was better. On 27Oct2021 (Wednesday), took medicine at 07:00 very few eggs, took folic acid Omega 3, plus quercetin. Drank tea with ginger and honey. Did not feel better until 16:30, after visit, took medicine famotidine (FAMOTIDINE, strength: 20 mg) taken for acid reflux and omeprazole (OMEPRAZOLE, strength: 40mg) taken to protect stomach Lining. Then 1/2 of ibuprofen at bedtime took magnesium and Benadryl. She also took naproxen (NAPROXEN, strength: 500 mg) taken for pain. On 28Oct2021, Thursday woke up had few aches. Took her antacid, folic acid, omega-3 and quercetin. Had blood work done and then came home and took magnesium pill at 09:30 and she was feeling fine. Took 2nd pepcid and magnesium. Her back hurt but felt ok most of the evening took magnesium and Benadryl at night-time. On 29Oct2021, (Friday), felt good this morning took pepcid, stomach protector, magnesium, quercetin, Zinc, omega-3, folate. Drank some coffee felt a great most of the day. Took a leave around lunchtime. Had a few aches come night-time but she laid on heating pad and was ok! took magnesium and Benadryl. On 30Oct2021 05:00, took same medicines. Felt ok this morning but these three doses seem to give more aches in her upper back lately much better than her chest but still annoying. Took Aleve at lunch and the better spending lot of time on the heating pad. she had also had two rounds of IV vitamin infusions, which have helped significantly. On 31Oct2021 (Saturday) felt great all day continued with the same medications omega 3, folic acid, pepcid, quercetin, omeprazole, naproxen at lunchtime only. Doing the same today 01Nov2021, it does seem improving but it seems very slow. The patient was visited to doctor or other healthcare professional office/clinic and emergency room/department or urgent care for her events. The patient underwent lab tests and procedures which included on 30Sep2021 EKG: normal, 01Oct2021 EKG: fine, on 04Oct2021 echocardiogram: heart looked fine but did see heart palpitations, on 28Oct2021 CK blood test: came back normal, on an unspecified date regular blood test: result unknown, on 11Oct2021 EKG: looked fine and on 01Oct2021 nasal swab test (sars-cov-2 test) resulted in negative. The outcome of the event body aches and I had aches and fatigue/ body aches was recovered on 24Sep2021 and the outcome of the event Heart palpitations was recovered on 07Nov2021 while the outcome of the remaining events was recovering and the outcome of the Aches in my upper back was not recovered. No hospitalization prolonged, treatment received for the event.  No follow-up attempts are possible. No further information is expected.  Follow-up (09Nov2021): This is a follow-up spontaneous report received from a contactable consumer (patient). This consumer reported in response to non-hcp letter sent which included: Updated Clinical information, treatment medication and the outcome of the events.  Follow-up attempts are completed. No further information is expected.