Age: 62.0
Sex: F
Vaccine: COVID19
Symptoms: Cough, Dyspnoea, Lethargy, Nasal congestion, Oropharyngeal pain
Clinical narrative: Lethargic; sneezing and coughing is so severe that it makes her makes her pee; Low pulse ox reading; Difficulty breathing; Sneezing; sneezing and coughing is so severe that it makes her makes her pee; Congestion; Severe sore throat; This is a spontaneous report received from a contactable consumer (patient herself). A 62 year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration in left upper arm on 23Apr2021 11:45 (Batch/Lot number was not reported) as 1st dose, single for COVID-19 immunisation. Medical history included ongoing GERD (has had this since her injuries, so about 10 or 11 years), ongoing asthma (she was diagnosed with this probably 15 years ago on the job), ongoing Bi-valve of her aorta, it is a leaky valve diagnosed in 1994, multiple injuries (sustained on the job; had accidents and different things, and surgeries too; injuries were cumulative over 22 years on the job), bronchitis (started because she had pneumonia in 1996 then any respiration issue turned into bronchitis; has had repeated bronchitis over the past 17 years; been using her inhaler), environmental allergies, adverse reactions to opioids and pain medicine, LS fusion in 2010, CS fusion in 2012, left shoulder surgery in 2012, gallbladder removal in 2016, total hysterectomy in 2005, tonsillectomy/adenoidectomy in 1977. She had no relevant family medical history. Concomitant medications included montelukast sodium (SINGULAIR) taken for allergies from 2006 and ongoing; fluticasone furoate, vilanterol trifenatate (BREO ELLIPTA) taken for asthma from 2016 and ongoing; azelastine hydrochloride, fluticasone propionate (DYMISTA) taken for hypersensitivity from 2016 and ongoing; dexlansoprazole (DEXILANT) taken for indigestion from an unspecified start date and ongoing; cyclobenzaprine hydrochloride (FLEXERIL) taken for pain and muscle relaxant for multiple injuries from her job from 2013 and ongoing; and ibuprofen (ADVIL) taken for pain and aches from an unspecified start date and ongoing. Patient previously received amoxicillin and was allergic. The patient had no prior vaccinations within 4 weeks. She was not sick at the time of vaccination and that she was unbelievably healthy. In the early evening of 10May2021, the patient experienced severe sore throat that was persistent to worsening. In the evening of 11May2021, she experienced coughing and congestion. On 12May2021, the patient had low pulse ox reading and she was feeling crappy. Her pulse ox has not gotten above 95% since last night and that it was 93% at the time of report. It occurred late last night and hasn't gone up. She checks it every night. Pulse oximetry taken around 22:00 on 12May2021 was 93%. Patient said she knew this from over the years she's had bronchitis. She also reported worsened difficulty breathing in the morning, sneezing and coughing was so severe that it made her pee. It occurred in the morning and she  had to change her jammies. It happens when the coughing and sneezing was severe. She thinks the congestion was causing the coughing. She was lethargic a few days after the first dose; she felt crappy. She was so tired and she wondered if her immune system dumped and that's why she got sick. She says the lethargic feeling occurred mid morning a few days after the first dose, but exact date was unknown, then clarified she does not know if event started one or two days after the shot. She could not find the NDC number, LOT number, or expiration date on her vaccination card. She called her lung doctor and couldn't get in. She will be calling her primary because they weren't open yet. When asked if the events required a visit to the Emergency Room, the patient said "no, not yet." She confirmed that her next dose was on Friday 14May2021, and mentioned: I lost my days-further details not provided. Patient wanted to ask if she should proceed with that schedule despite how she's feeling. Outcome of severe sore throat was unknown, and of remaining events was not recovered.  Information about the batch/lot number has been requested.