Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, Bone pain, Insomnia, Loss of personal independence in daily activities, Muscular weakness
Clinical narrative: She couldn't lift her arms for weeks and weeks after that.  Says it almost feels like there is a weakness in her arm;; It has been hard to sleep; It is just enough to where she cannot do anything.; I'm having trouble with pain in that arm that they gave me the shot in; The pain travels from shoulder to neck and it has been over two weeks.; The pain travels from shoulder to neck and it has been over two weeks.; States that her right arm is painful, feels like right down to the bone.; States that her right arm is painful, feels like right down to the bone.; This is a spontaneous report from a contactable consumer (patient). A 70-year-old female patient received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, formulation: solution for injection and Batch /lot number: not reported) via an unspecified route of administration, administered in right arm on 13Mar2021 (at the age of 70-year-old) at 10:30 as Dose 1, Single for covid-19 immunisation. Medical history included ongoing diabetes (diagnosed a long time ago, since her 40s or 50s), ongoing Breathing Problems (Stated that she doesn't take nebulizers or anything like that), she was a smoker for 50 years and got pneumonia 2 years ago and quit smoking cold turkey, she tried all the stuff that they have to replace nicotine and none of it worked. Stated that if she had to walk up a hill with any amount of speed she would be huffing and puffing really bad and would not be able to do it; ongoing blood pressure, ongoing cholesterol, ongoing vitamin supplementation, ongoing good for heart, Patient states that a few years ago she fell and messed up tendons and muscles. Stated that she was a heavy woman. Concomitant medication included ongoing glimepiride taken for diabetes; ongoing lisinopril taken for blood pressure; ongoing pravastatin (for blood cholesterol; ongoing insulin human (NOVOLIN R) taken for diabetes mellitus; ongoing metformin taken for diabetes; ongoing insulin taken for diabetes; ongoing omega 9 fatty acids, omega-3 fatty acids, omega-6 fatty acids taken for vitamin supplementation; ongoing vitamin d3 taken for vitamin supplementation; ongoing aspirin [acetylsalicylic acid] taken for heart (Stated she doesn't think a doctor ever told her to take aspirin, she heard it was good for her heart so she has taken it for years); ongoing calcium/magnesium taken for vitamin supplementation. Patient stated, she was having trouble with pain in that arm that they gave her the shot in 14Mar2021. It's been going on for over 2 weeks. The arm the shot was given in was painful. Patient was fine on 13Mar2021, and her arm started being sore on 14Mar2021. Patient stated that her right arm was painful, feels like right down to the bone on 14Mar2021. The pain travels from shoulder to neck and it has been over two weeks. It will seem like it was a little better in the morning when she gets up, then it goes right back to how it has been. It has been hard to sleep. Stated normally lays on right side. If she lays on that arm now its painful and if she rolls onto her left side, there's no comfortable place to put her right arm. Doesn't know how long this will last or is it something normal. She couldn't lift her arms for weeks and weeks after that. Says it almost feels like there was a weakness in her arm; though it was now not as bad as when she fell. Patient mentioned that her injection site has not healed. It increased up to the third day and then it stayed the same since third day. Does not seem to be getting better or worse. It is just enough to where she cannot do anything. Stated she was positive it was from the shot, either something that happened when they gave her the shot or the shot itself, then states the site of her injection was not healed. The outcome of the events weakness of arms, sleep difficult and activities of daily living impaired was unknown while the outcome of the other events was not recovered.  No follow-up attempts are possible; information about lot/batch number cannot been obtained.