Age: 46.0
Sex: F
Vaccine: COVID19
Symptoms: Body temperature, Chills, Fatigue, Feeling abnormal, Feeling hot
Clinical narrative: Headache at base of skull; Had fever with temperature of 101.2F; feeling very warm; Migraine; felt like a throbbing too tight cap around the skull]; 29Apr injection left arm in deltoid [inj site may have been a little low on the deltoid]; As time passed gradual onset of Left upper arm pain/ache from inj site radiating to left elbow; chills; Fatigued; Body aches; nausea; This is a spontaneous report received from a contactable reporter(s) (Pharmacist). The reporter is the patient.  A 46 year-old female patient (not pregnant) received bnt162b2 (BNT162B2), intramuscular, administered in arm left, administration date 29Apr2021 09:15 (Lot number: EP6955) at the age of 46 years as dose 2, single for covid-19 immunisation. Relevant medical history included: "GERD" (unspecified if ongoing); "Migraines" (unspecified if ongoing). Concomitant medication(s) included: AZELASTINE;FLUTICASONE; ZEGERID [OMEPRAZOLE;SODIUM BICARBONATE]; CALCIUM; NAPROXEN; ACETAMINOPHEN; ADVIL MIGRAINE; RIZATRIPTAN; FISH OIL; VITAMIN D NOS; VITAMIN C [ASCORBIC ACID]. Vaccination history included: Bnt162b2 (DOSE 1, SINGLE, lot Number: EP6955, Lot unknown: False, Administrator route: Intramuscular, Administration time: 09:15 AM, Vaccine location: Left Arm), administration date: 08Apr2021, when the patient was 46 years old, for Covid-19 Immunization. The following information was reported: PRODUCT ADMINISTERED AT INAPPROPRIATE SITE (non-serious) with onset 29Apr2021 09:15, outcome "unknown", described as "29Apr injection left arm in deltoid [inj site may have been a little low on the deltoid]"; VACCINATION SITE PAIN (non-serious) with onset 29Apr2021, outcome "recovering", described as "As time passed gradual onset of Left upper arm pain/ache from inj site radiating to left elbow"; CHILLS (non-serious) with onset 29Apr2021, outcome "recovering", described as "chills"; FEELING HOT (non-serious) with onset 30Apr2021 03:30, outcome "recovering", described as "feeling very warm"; HEADACHE (non-serious) with onset 30Apr2021 12:30, outcome "recovering", described as "Headache at base of skull"; FATIGUE (non-serious) with onset 29Apr2021, outcome "recovering", described as "Fatigued"; MIGRAINE (non-serious) with onset 30Apr2021, outcome "recovering", described as "Migraine"; NAUSEA (non-serious) with onset 29Apr2021, outcome "recovering", described as "nausea"; FEELING ABNORMAL (non-serious) with onset 30Apr2021, outcome "unknown", described as "felt like a throbbing too tight cap around the skull]"; PAIN (non-serious) with onset 29Apr2021, outcome "recovering", described as "Body aches"; PYREXIA (non-serious) with onset 30Apr2021 04:50, outcome "recovering", described as "Had fever with temperature of 101.2F". Relevant laboratory tests and procedures are available in the appropriate section. Therapeutic measures were taken as a result of vaccination site pain, chills, feeling hot, headache, fatigue, migraine, nausea, pain, pyrexia. Additional information: The patient did not take any other vaccine in four weeks. 29Apr2021 injection left arm in deltoid [inj site may have been a little low on the deltoid] around 9:15 am. As time passed gradual onset of Left upper arm pain/ache from inj site radiating to left elbow. Visually her arm looked normal. Pain was about 5 out of 10. Around midnight experienced chills after using ice pack for left arm pain & body aches. Partially woke up around 3:30 am on 30Apr2021 feeling very warm. Completely awake & had fever with temperature of 101.2F at 4:50 am 30Apr2021 with headache at base of skull. Took 1 gm Tylenol. Fever broke and temp was 98.8 at about 8:30 am but fatigued & headache worsened to migraine [felt like a throbbing too tight cap around the skull] with nausea. Migraine pain was about 10 /10. Took Rizatriptan 10 mg at 9:14 am. at 11:39 am migraine was still bad so took three 200 mg tablets of Advil [total 600 mg] & went back to bed with ice pack for head. Headache abated around 12:30 pm 30Apr. Mild residual headache pain w/ fatigue as of 6:58 pm. AE treatment: Tylenol, Rizatriptan, Advil, ice packs. The patient did not had Covid prior vaccination. The patient was not tested for Covid post vaccination.  No follow-up attempts are possible. No further information is expected.