Age: 57.0
Sex: F
Vaccine: COVID19
Symptoms: Pain in extremity, Platelet count, Thyroid function test, Troponin, Vaccination site erythema
Clinical narrative: pain in her left armpit gradually got worse and moved to her hand and all of her left arm; pain in her left armpit gradually got worse and moved to her hand and all of her left arm; pain on the side and above her left breast; her cholesterol is good except her triglycerides; she had a feeling of indigestion; she woke up with upper left back behind shoulder blade pain; more pain and swelling and redness at the injection site; more pain and swelling and redness at the injection site; more pain and swelling and redness at the injection site; This is a spontaneous report from a contactable consumer (patient). A 57-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), dose 2 via an unspecified route of administration, administered in Arm Right on 08Apr2021 15:00 (Batch/Lot Number: EW0151) as SINGLE DOSE for covid-19 immunisation, at 57 years old on a mass vaccination site. Medical history included ongoing chronic bronchitis, diabetic (blood sugar is under good control), Chronic Obstructive Pulmonary Disease, ongoing gastrooesophageal reflux disease (GERD), Gastroparesis, ongoing essential hypertension, benign, ongoing Mixed hyperlipidemia, ongoing hypoxia, ongoing obstructive sleep apnea, ongoing Lymphedema, ongoing Osteoarthritis, ongoing Vitamin D deficiency, she is a smoker (she's trying to quit with patches), pain, normally high platelets and been on pain medicine several years due to low back pain; all from unspecified dates. She received SHINGRIX vaccine on 25Jun2019 and reported the first shot of her Shingrix vaccine was really painful. She received the first dose of BNT162B2 (Lot number: ER8727) on 18Mar2021 10:30 in the left arm and she had minimal injection site pain that resolved, age at vaccination was 57 years old. Concomitant medication included hydrocodone bitartrate, paracetamol (HYDROCODONE/ACETAMINOPHEN) taken for pain from an unspecified start date and ongoing; guaifenesin taken for an unspecified indication, start and stop date were not reported; acetylsalicylic acid, caffeine (BAYER BACK & BODY PAIN) taken for pain, start and stop date were not reported. The patient previously took baby aspirin from an unspecified date and experienced bothering her stomach. No other vaccinations within 4 weeks.The patient woke up with upper left back behind shoulder blade pain on 11Apr2021 which got worse as the day went on. She normally coughs every day because she has chronic bronchitis and it has been very painful to cough. Around 4 PM, pain in her left armpit gradually got worse and moved to her hand and all of her left arm on 12Apr2021. She also had pain on the side and above her left breast on 12Apr2021. The pain was so severe she went to the ER the night before because she was concerned, she might have been having a heart attack. The ER checked her out and found nothing and she followed up with her primary care doctor and has not gotten a response yet. There was more pain and swelling and redness at the injection site (on 08Apr2021) and it took a little bit longer to resolve but it has resolved. On 11Apr2021, she woke up with a terrible pain in her back under her left shoulder blade and as the day went on it, the pain got worse as the day went on, so she used a heating pad and a handheld vibrating pad for about an hour. She developed a bad pain that came on gradual in her left armpit. She went to bed with the heating pad on her back and yesterday, 12Apr2021, the pain was worse. When she coughed there was extreme pain. She normally coughs up phlegm every day because she has chronic bronchitis and it has been very painful to cough. After a while she could feel the pain in her left hand coming up her left arm. Essentially her whole left arm, left breast and above her left breast. She called the urgent care and called her primary care doctor's after-hours service and spoke to the doctor. She was worried about a heart attack or side effect of the vaccine and the doctor on call advised her to go to urgent care or emergency department for an EKG.  She went to the emergency department around 8:30 PM. It took her an hour to get in a room. The emergency department did an EKG, they took blood and inserted an IV, but they didn't give her medication in the IV. She got a nitro paste patch on her left chest. She also got 3 baby aspirin to chew (a preventative for her heart. Aspirin 81mg Equate brand, low dose chewable), and a chest X-ray. The emergency room didn't see anything. Everything looked good or normal. The emergency room was looking for an elevated troponin which would indicate heart trouble and her troponins were not elevated. While the emergency department nurse was going over this information with her, she had a feeling of indigestion on 12Apr2021, so she was given a GI cocktail. The nurse told her it would numb her mouth and not to eat or drink for 30 minutes. It was a thick liquid. It was to coat her stomach. She doesn't know what was in the medication. Her symptoms are possibly related to the COVID 19 vaccine in her mind because she received her second vaccine on Thursday 08apr2021 and started having these pains on Sunday, 11Apr2021. She doesn't know what else to do. The pain could be from several things and she's concerned. She reports her white blood cell counts are normal for her. Her platelets are slightly high, but they are normally high for her. Her A1C is in range at 4.6%. Her thyroid is normal, her vitamin D is good, and her cholesterol is good except her triglycerides (12Apr2021). Her pain medicine is not touching this pain that she's having. The patient underwent lab tests and procedures which included blood cholesterol: good except her triglycerides, blood test: unknown results, chest X-ray: unknown results, electrocardiogram: unknown results, glycosylated haemoglobin: 4.6 %, platelet count: slightly high, troponin: were not elevated, white blood cell count: normal on 12Apr2021. Therapeutic measures were taken as a result of she woke up with upper left back behind shoulder blade pain; pain in her left armpit gradually got worse and moved to her hand and all of her left arm (pain in extremity and axillary pain); pain on the side and above her left breast; and she had a feeling of indigestion. Events required emergency room visit. Outcome of the events upper left back behind shoulder blade pain, pain in her left armpit/moved to her hand and all of her left arm was not recovered. Outcome of the events more pain and swelling and redness at the injection site was recovered on an unspecified date. Outcome of the other events was unknown.