Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Pyrexia, SARS-CoV-2 test, Tenderness
Clinical narrative: discomfort in the deltoid at a certain range of positions; tenderness; entire deltoid muscle having limited range of motion; low grade temperature; achy; By that night my arm was very sore/I woke up with moderate to severe pain in my entire right deltoid radiating to the entire muscle to my shoulder blade; arm was a little sorer than the first time, tenderness in the deltoid muscle; This spontaneous case was reported by a nurse and describes the occurrence of MOBILITY DECREASED (entire deltoid muscle having limited range of motion), MUSCLE DISCOMFORT (discomfort in the deltoid at a certain range of positions), TENDERNESS (tenderness), PAIN (achy) and PAIN IN EXTREMITY (By that night my arm was very sore/I woke up with moderate to severe pain in my entire right deltoid radiating to the entire muscle to my shoulder blade) in a 74-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 003B21A and 031A21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below.     Concurrent medical conditions included Drug allergy, Bone disorder NOS, Eye disorder NOS and Reflux gastritis. Concomitant products included CALCIUM for Bone disorder NOS, ASCORBIC ACID, CUPRIC OXIDE, DL-ALPHA TOCOPHERYL ACETATE, XANTOFYL, ZEAXANTHIN, ZINC OXIDE (PRESERVISION AREDS 2) for Eye disorder NOS, FAMOTIDINE (PEPCID [FAMOTIDINE]) for Reflux gastritis.   On 23-Apr-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 21-May-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On 23-Apr-2021, the patient experienced MYALGIA (arm was a little sorer than the first time, tenderness in the deltoid muscle). On 21-May-2021, the patient experienced PAIN (achy), PAIN IN EXTREMITY (By that night my arm was very sore/I woke up with moderate to severe pain in my entire right deltoid radiating to the entire muscle to my shoulder blade) and PYREXIA (low grade temperature). In June 2021, the patient experienced MOBILITY DECREASED (entire deltoid muscle having limited range of motion). On an unknown date, the patient experienced MUSCLE DISCOMFORT (discomfort in the deltoid at a certain range of positions) and TENDERNESS (tenderness). The patient was treated with PARACETAMOL (TYLENOL) at a dose of 1 dosage form and IBUPROFEN in June 2021 at an unspecified dose and frequency. On 23-May-2021, PAIN (achy) and PYREXIA (low grade temperature) had resolved, MYALGIA (arm was a little sorer than the first time, tenderness in the deltoid muscle) outcome was unknown. At the time of the report, MOBILITY DECREASED (entire deltoid muscle having limited range of motion), MUSCLE DISCOMFORT (discomfort in the deltoid at a certain range of positions) and TENDERNESS (tenderness) outcome was unknown and PAIN IN EXTREMITY (By that night my arm was very sore/I woke up with moderate to severe pain in my entire right deltoid radiating to the entire muscle to my shoulder blade) had resolved.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 06-Jan-2021, SARS-CoV-2 test: positive (Positive) positive.     For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments.   Patient reports she experienced a LowGrade Fever, results were not provided.  Treatment included ice.     This case was linked to MOD-2021-250596 (Patient Link).   Most recent FOLLOW-UP information incorporated above includes: On 31-Jul-2021: Significant follow up received on 31-JUL-2021 include concomitant drugs added, treatment information provided and new event Pain in arm updated.