Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Gait disturbance, Intervertebral disc protrusion, Magnetic resonance imaging, Neck pain, Pain
Clinical narrative: This is a spontaneous report from a contactable consumer (patient). A 70-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration, administered in right arm on 01Apr2021 15:45 (Batch/Lot Number: EW0151; Expiration Date: 31Jul2021) as 2ND DOSE, SINGLE for covid-19 immunization. Medical history included ongoing arthritis, ongoing depression, ongoing anxiety, ongoing tardive dyskinesia, ongoing balance disorder for maybe 3 or 4 years. When probing medical history and concomitant medications, she reports she has arthritis, depression, anxiety. She reports she takes a few psychiatric drugs but declines to add those to the report. She reports she has Tardive Dyskinesia and gets Botox injections in her temples and jawlines every 3 months. Her last Botox injection was one month ago. Concomitant medication included botulinum toxin type a (BOTOX) taken for tardive dyskinesia, start and stop date were not reported. The patient received first dose of Covid 19 vaccine (Lot number: EN6205, Expiry Date: Jun2021) on 10Mar2021 at 12:30PM administered in right arm for Covid-19 immunization. For any Tetanus vaccine or Flu vaccine that may have caused her a sore arm in the past. No prior Vaccinations (within 4 weeks). No other vaccines administered on same date with the Pfizer vaccine considered as suspect. The patient received the second dose of the Pfizer COVID-19 vaccine on 01Apr2021. She had fever, body ache and chills one day post vaccination (02Apr2021). The symptoms lasted until 03Apr2021. She didn't have any other symptoms until 2 weeks later. She started having an arthritis pain in her hips, knees, shoulder, and toes. The pain is quite significant. She wants to know if this is was part of an immune response to the vaccine. The worst pain she is having is on the right side. Its the same side in which she received the vaccine. Caller states she was under the care of a doctor for pain management. She was going to start getting injection maybe cortisone. She felt everything flared up. She went to the emergency room and received 2 shots of morphine. She cant even bend over she feel like going to the E.R and getting another shot of morphine to help ease the pain. A couple weeks ago, she noticed she was having some arthritis pain. She had been told in the past that she has arthritis. She had arthritis pain in her hip, knees, shoulder, and toes. She went to the emergency department and had a CAT scan and saw she had a herniated disc in her back. The emergency room thinks the herniated disc in her back was causing her back pain. All of her joints hurt. Her hip hurts so bad she can hardly take a breath. She was asking is this an arthritis flare up or an immune response from the COVID-19 vaccine. She was asking if this was related to the COVID-19 vaccine. She's going to have steroid injections in her foot. She has arthritis in her big toe and she has bunions. Last week she had cellulitis in her right foot and she could hardly walk. From her neck down she hurts. She took some muscle relaxers and she's having trouble talking because of the medicine. She takes Tizanidine and Hydrocodone. She took some and her back feels better but her hip is horrible. Hydrocodone-Acetaminophen 7.5mg-325mg. Take one tablet twice a day as needed. In a pharmacy bottle, NDC/Lot/Expiry not known. Tizanidine 4mg. Take one to two tablets two times daily as needed. In a pharmacy bottle, NDC/Lot/Expiry not known. Discard by date on pharmacy bottle is Apr 2022. She went for a follow up with her primary care provider after she went to the emergency room and her primary care doctor told her she can't do anything for her. The doctor didn't even ask her a question. That's not the first time the doctor has done that. She's looking for a new doctor. She reports two weeks ago she was able to hold her granddaughters for the first time in 14 months since the pandemic started. She reported her initial side effects of fever, body aches and chills lasted about a day then the day after on 03Apr2021, those side effects were gone. Except for a sore arm. She had a sore arm for 2 to 3 days. Her arm felt like getting a flu shot. But the next day it felt more like getting a tetanus shot. The arthritis pain has been gradual. First she noticed her thumbs would be sore and her thumbs have been fine for quite a while. Meaning, she hasn't had arthritic pain in her thumbs for a while. She woke up this morning and everything hurts. It's gotten worse. She also has pain that goes down her leg. This pain is associated with the herniated disc but she can't remember what it's called. While in the emergency department she had a CAT scan and routine blood work done. She had an MRI scan last Saturday, 01May2021. She doesn't know the results of that yet. Her pain management doctor thought she had a herniate disc. She has back pain and was told a while ago that she does have arthritis. If she aches, it's the arthritis. A week or so before she went to the emergency department she fell twice and landed on her bottom both times. She didn't have to go to the emergency department for either of her falls. She just had some bruises. She reports she's had balance problems for maybe 3 or 4 years. She reports she went to the emergency room only once and it was about 3 weeks ago. She would like to add that the worst pain she's having is on the right side of her body. Relevant Tests included blood work, CAT scan and MRI. The outcome of event Fever, body aches, chills were recovered on 03Apr2021, of arthritis, herniated disc in her back, back pain, hardly take a breath, was not recovered, of other events was unknown. No follow-up attempts are needed. No further information is expected.