Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: Vaccination site erythema, Vomiting, X-ray
Clinical narrative: upset stomach; Aches and pains in her whole body; Fevers; Nausea; Bit short of breath; Left upper arm is stiff; Rash in different parts of her body; Headaches; Redness around the injection site; Muscle aches; Vomited once; Pulse ox around 92-93; Throat is not clear; Itching; This is a spontaneous report from a contactable physician. A 56-years-old female patient received BNT162B2 (Formulation; Solution for injection; Batch/Lot Number: ER8734) via an unspecified route of administration, administered in Arm Left on 31Mar2021 as DOSE NUMBER UNKNOWN, SINGLE for covid-19 immunisation. Medical history included ongoing Contact allergy to nickel (She can't wear custom jewelry because her skin breaks out immediately. In a few hours her skin breaks out at the site where she wears custom jewelry. The allergy to nickel has been a long time, since she was young. She has always had that when she tried to wear jewelry since she was a teenager), ongoing Partial lactase deficiency (She can't eat a lot of milk or dairy products. The lactase deficiency also definitely started when she was young since childhood), Antihypertensive and slows the heart rate from an unknown date and unknown if ongoing, Immune boost against viruses from an unknown date and unknown if ongoing. Concomitant medications included bisoprolol (BISOPROLOL) 5mg, in the morning taken for Antihypertensive and slows the heart rate, heart rate abnormal from an unspecified start date and ongoing; zinc (ZINC) 50mg, one in the morning and one in the afternoon taken for Immune boost against viruses from an unspecified start date and ongoing; acetylsalicylic acid (ASPIRIN PROTECT) 100mg, one every day taken for an unspecified indication, start and stop date were not reported. On 31 Mar2021 caller is reporting regarding side effects from the Pfizer Vaccine. She got it at the Center. She clarifies it is the covid vaccine. She has a sheet that says it was manufactured by Pfizer Biotech, it has a fact sheet, and it says emergency use authorization to prevent Covid-19 in those 16 and older. First, she had the injection into her left upper arm yesterday at around 1430 to 1500. Her appointment was around 1400 and by the time she got it, it was past 1400. Immediately after nothing happened. It happened mostly after she came back home within a half hour to an hour. Within 2 hours she had aches and pains in her whole body, something as if somebody had beaten her up. Her arm, her upper arm mostly, where she got the injection is stiff. It is very painful, and she has some redness around the injection site. She also has a rash that started around her belly and is now in different parts of her body. She also has muscle aches. She had a very strange feeling yesterday within 2 hours or after, she started to have headaches. It was more like a flushing in her head. It was as if her head was kind of not able to focus and with some pain like a headache. She also had nausea and vomited once. She took an antihistamine over the counter, something like Claritin, because she also felt a bit short of breath. She did taker her pulse ox and it was around 92-93 yesterday. Today it improved after taking Claritin. So today she still has the rash and her whole body is aching, she still has a headache, and her arm is really sore, and she can't move it. She asks to have that written down, she can't move her arm near the shoulder and it really aches. It is not like the injection, she didn't have it right away, it was within an hour or so, or within 2 or 3 hours she started having the aches and pains. Reporter prefers her main contact to be by email. Her phone is not reliable, and she is in and out of the place where she is living. She declines to give her mailing address right now. She would rather stick with email right now; it would probably be the best way to do that. She has a question. Does she have to be seen by a doctor. She, as a medical doctor, doesn't think she has to go to the emergency room. Her symptoms have improved, and she has no acute chest pain. Her pulse ox dipped yesterday, but today it is better. Her shortness of breath is definitely better today after she started the antihistamine. She asks if we by law have to say that she needs to go to the physician. The weather is bad where she is, and they are having snow there. All health facilities and doctors are overwhelmed right now with the Covid situation. She improved with the antihistamine and will try to make an appointment as soon as possible. She obviously took an anti-inflammatory. Her headache is still there. She will keep taking the anti-inflammatory and the antihistamine. She does have, if we want, the code number where they registered her at the vaccination center. She got the vaccine there in the (vaccination center name) in (location). She has to say this, she hasn't visited a general doctor in a long time and will have to call in in order to make an appointment with one. In the past she saw a doctor, her name was (Dr. name) with the (hospital name). She also has seen an ENT before. She doesn't have contact information for Dr. (name). We can probably pull her up, she used to practice in (location). She is not on a lot of medications recently. She has been on some medications because of Covid prophylaxis. She is on an antihypertensive, Zinc, and Concor for heart rate. The Concor is Bisoprolol. She took that before she had the vaccine. She has been on it for more than a year, almost 2 years or so. Her muscles literally feel as if they've been beaten up. It mostly started yesterday. She slept and wanted to rest. She started feeling the aches and pains 3-4 hours after she got the vaccine and then this morning it was really pronounced. Patient received treatment with Tylenol for the pain, an anti-inflammatory, and Claritin. All the medications that she takes will expire after 2023, way after 2021. She pays attention to all food and medication expiration dates. She is trying to see where the lot is on her Tylenol. She can't see very well. They have code that is like a purchase code but not a lot number. There is a barcode thing but because of the carton it is not very clear. It is hard to see the numbers. She is not going to be able to give product information for the Tylenol. She did take Claritin yesterday when she felt there was something going on with the pain and not breathing very well. She forgot this could have an anti-allergic affect. Claritin has an antihistamine effect. If she were to provide any information for any medications, she would have to get her magnifier. Right now, she is taking Bisoprolol 5mg in the morning. She is taking Aspirin Protect Bayer 100mg, she takes one every day. She is taking Zinc 50mg, one in the morning and one in the afternoon as an immune boost and against viruses. She takes Vitamin C 1000mg, she breaks it in half and takes one half in the morning and one half in the afternoon. Those are the main medications. The Bisoprolol is used as an antihypertensive and slows the heart rate. She started having fevers of more than 100.5. She also started having pains, generalized pains all over her body mostly on her left upper arm. This seems to have started the same day a few hours after the vaccine. Everything started a few hours after the vaccine. She came back and slept early; she really wasn't feeling well. When she woke up in the morning and still had the symptoms and the rash. Her aches improved a little after taking Tylenol and Aspirin. She believes she took Advil as well and anti-inflammatories. In the morning she woke up and was still having it. After she ate, she took another Tylenol. She also took Claritin. The shortness of breath also started yesterday but when she took Claritin it did improve in the morning. Her fever improved after the Tylenol. She still has nausea and an upset stomach. She vomited once yesterday. This morning she didn't vomit but is still not feeling like she needs to eat because of her upset stomach. She is nauseous like her whole stomach is not receptive. Even when drinking water, she can only take a few sips. Her pulse ox was dipping from 91-92 today. With the Claritin it might have improved. Because her pulse ox is better right now, she didn't go to the emergency room. She knows that anything below 94 should get medical attention in the emergency room or something. Right now, she is 94, 95, 96 range. Her throat is not clear, every so often she has to swallow saliva and kind of like clears her throat in order to free her situation. Her pulse ox right now is okay. Her upper arm hasn't improved. She can't put weight on her arm of lift anything. She has the rash on her legs and abdomen. It more not only at the site of the injection but around her skin in general. It is itching and feels like she needs to itch. It started yesterday. She noticed it mostly this morning. She wants to convince herself that it is getting better. Her headaches are not like regular headaches, it is more a feeling like her head is heavy and kind of flushed and with pain. It did improve a bit with Tylenol. Except for the medications she is taking, she does have a contact allergy to nickel. She can't wear costume jewelry because her skin breaks out immediately. In a few hours her skin breaks out at the site where she wears custom jewelry. She also has a partial lactase deficiency. She can't eat a lot of milk or dairy products. She can have small amounts like partial. The allergy to nickel has been a long time, since she was young. Right now, she is 56-57, she was born in 1964. She has always had that when she tried to wear jewelry since she was a teenager. The lactase deficiency also definitely started when she was young since childhood. She was born with these things; they were not acquired allergies. She has not had any tests recently. She did have some sort of testing done like a head CT and a chest X-ray; she believes it was definitely more than 2 years ago. She has had nothing recent. They were normal.  Time the Vaccination Was Given Her appointment being 1400. It was a little past 1400, she wasn't looking at the hour. It was between 2 and 3 by the time she was seated, and they prepared. History of all previous immunization with the Pfizer vaccine considered as suspect: This was her first dose. She needed to wait a little, but they were advertising for the fact that they were not giving the Pfizer version anymore in the center. She figured the data on the Pfizer is the best, so she tried to get it before they changed the type of vaccine. She was thrilled by the results and effectiveness of the Pfizer vaccine. She will be trying to make an appointment. The weather is very bad there. Because she is in the medical field, she has been observing herself. If things get worse, she will go to the emergency room, otherwise she will try to make an appointment with the doctor. She has no transportation; she would have to take the bus or a taxi. She will have to see what to do. She asks if there are any pamphlets or forms that she should expect to get by mail or email. She says she would like to document these things as it is something she will have to follow up on and it is important to check. The patient underwent lab tests and procedures which included body temperature: 100.5 on 31Mar2021, head CT: normal 2 years ago. They were normal, oxygen saturation: around 92-93 on 31Mar2021 Yesterday, oxygen saturation: 91-92 on 01Apr2021 today, oxygen saturation: definitely okay on 01Apr2021 today, x-ray: normal 2 years ago. They were normal. The outcome of the events Aches and pains in her whole body, Fevers, Nausea, Bit short of breath, Rash in different parts of her body, Headaches, Redness around the injection site, Muscle aches, Throat is not clear, Itching was recovering. The outcome was not recovered for events Left upper arm is stiff, Upset stomach. Outcome unknown for Vomited once and Pulse ox around 92-93.  No follow-up attempts are possible. No further information is expected.