Age: 82.0
Sex: F
Vaccine: COVID19
Symptoms: Cough, Decreased appetite, Electrocardiogram, Myalgia, Nausea
Clinical narrative: chills; fever; total pain throughout the body; muscular pain; profound weakness; diminished appetite; nausea; dry cough; The important thing was her temperature temperature ally runs around 96.7 degrees Fahrenheit was 99.6 degrees Fahrenheit.; This is a spontaneous report from a contactable consumer (patient). An 82-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection), via an unspecified route of administration, administered in the left arm on 19Feb2021 at 12:30 (at the age of 82-years-old) (Lot Number: EN6200; Expiration Date: 30Jun2021) as dose 2, single for COVID-19 immunisation.  Medical history included open heart surgery from 30Apr2019 to 30Apr2019, rectal adenocarcinoma from 2016 to 2016, embolic strokes, chronic edema, coronary artery disease, AFib (atrial fibrillation), bilateral carotid artery surgery from 2016 to 2016, and congestive heart failure. Concomitant medications included rivaroxaban (XARELTO, strength: 15 mg) (also reported strength: 20 mg before) taken for an unspecified indication from 2013 and ongoing; diltiazem hydrochloride (CARDIZEM CD, strength: 120 mg) taken for coronary artery disease from an unspecified start date and ongoing; metoprolol tartrate (strength: 100 mg) taken for coronary artery disease from an unspecified start date and ongoing; potassium canrenoate (ALDACTONE, strength: 25 mg), and torasemide (TORSEMIDE, strength: 50 mg) taken for coronary artery disease, start and stop date were not reported. The patient previously took the first dose of BNT162B2 (Lot Number: EL9263; Expiration Date: 31May2021) on 29Jan2021 for COVID-19 immunisation. On 28Feb2021, the patient experienced chills, fever, total pain throughout the body, muscular pain, profound weakness, diminished appetite, nausea, dry cough, and the important thing was her temperature ally runs around 96.7 degrees Fahrenheit was 99.6 degrees Fahrenheit. The patient asked is it possible that she could have had these symptoms as a delayed reaction to the vaccine.  The clinical course was reported as follows: symptoms: further described to include chills; fever; total pain throughout her body; muscular pain; profound weakness. In addition to that she had diminished appetite of course. The important thing was her temperature which normally runs around 96.7 degrees Fahrenheit was 99.6 degrees Fahrenheit. She has been coughing and it is a dry cough, it does not produce any mucus or anything from her, does not bring up anything from that cough.  She has not seen her primary care provider about event. Patient called her office and they instructed her to call back if she was not feeling better in 2-3 days. She has not called back because she seems to not have the acute symptoms that she did have any longer. The one thing that stands out is relative to her cardiac history and open-heart surgery historically and she has limits as to how much activity she can feel comfortable doing without being exhausted. What she noticed with symptoms during this event starting about 28Feb2021 is she feels more exhausted in this time frame. It really caught her late Sunday, 28Feb2021: she was chilling so she got into bed early around 21:00-21:30 and woke up at about 03:30 01Mar2021 and she was in a very negative state; she had difficulty navigating; she needed to find her way to the bathroom and she had to hang onto everything around her to keep her from tipping over and then found her way out to the kitchen to get a glass of water; that was about 50 footsteps and took an Extra strength Tylenol at that time and she had a glass of water which she was able to keep down. She did have low grade nausea. So she found her way back to bed and she fell asleep and did not wake up until noon on 01Mar2021 which is highly unusual for her; even if she wakes in the middle of the night she is usually up by 07:00-07:30.  Symptoms are definitely less and improved dramatically from Monday, 01Mar2021 which was her low point. Tuesday, 02Mar2021 and Wednesday, 03Mar2021 she stayed close to home. She did not go out, had lots of chores to do and she could not muster up the energy. On Thursday, 04Mar2021 she finally got it together and went got in her car and drove to the bank, pharmacy and grocery store and then came home; so, she was out doing errands for about 2 hours. By the time she got home she was really low on body fuel; But she was happy that she was able to get out there and do what she needed to do. Regarding relevant testing/investigations she reported none since prior to vaccines; the last time she had lab work done was 12Jan2021 when she had a repeat of her EKG and a basic chem panel. The doctor said everything was within normal limits; and her EKG was consistent with her medical history and issues. The outcome of the events was recovering/resolving.   No follow-up attempts are needed. No further information is expected.