Age: 61.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Lethargy, Myalgia, Nausea, Pain, Pain in extremity
Clinical narrative: Sick; Arms ached; Extreme Fatigue; low grade temperature; Severe chills; dull headache; 2nd Day. Feeling lethargic no energy; 2nd Day. Feeling lethargic no energy better at night; nauseated; body and muscle aches/severe body aches; body and muscle aches; This is a spontaneous report from a contactable consumer (patient). A 61-year-old non-pregnant female patient received second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, formulation: solution for injection, lot number: EP7534, expiry date: unknown) (age at the time of vaccination was 61 years, patient was non-pregnant at the time of vaccination), administered in arm left on 19Mar2021 at 10:30 as DOSE 2, SINGLE for COVID-19 immunisation. The patient's medical history included asthma, Lichen's sclerosis. The patient known allergies to penicillin, amoxicillin, erythromycin, clindamycin. It was reported that the patient was really sick for a week but that was after the second dose of the measles, mumps, and rubella shot at the age of 42 years in 2012. Concomitant medications included Livalo, Synthroid, Flovent, Vitamin D, Vitamin C and Probiotics. The patient did not take any other vaccine in four weeks prior COVID -19 vaccine. She was not diagnosed with COVID prior vaccination and tested negative with COVID post vaccination. Patient previously received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, formulation: solution for injection, lot number: EN6202), via an unspecified route of administration, administered in arm left on 26Feb2021 10:30 as DOSE 1, SINGLE for COVID-19 immunisation. On 19Mar2021 at 13:00, after the second shot, patient had dull headache, feeling lethargic no energy better at night 3rd day fine most of day then body and muscle aches at 8 pm 4th day done most of day until 1 pm nauseated better in 3 hours 8pm that night body and muscle aches. No post COVID test was performed after the second dose. On 28Apr2021, patient had second occurrence of headache. The caller stated after the second vaccine she had side effects 2 and 3 days but now it was six weeks later and she lives very carefully and she has come down with severe body aches, chills, low grade temperature, nausea and she was sick for about a week and there were still some residual symptoms but she was much better. It was reported that the patient had severe chills and could not get warm. The patient stated that yesterday morning her arms ached but that went away after taking Tylenol. Arms ached stopped within a 4 hours period. The patient also experienced fatigue. The patient underwent lab tests and procedures, which included PCR COVID test: negative. Therapeutic measures were taken as a result of arms ached and included treatment with Tylenol and no treatment received for other events. The patient did not visit emergency room/physician office. The outcome of the events dull headache and low grade temperature resolved on 30 Apr2021, nauseated resolved on 02May2021, severe chills and arms ached resolved on 05May2021, The outcome of the event sick was unknown and for other events outcome was resolving.  No follow-up attempts are possible. Information about lot/batch number cannot be obtained.