Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Pain, Pain assessment, Vaccination site pain
Clinical narrative: Headache; Pain was located adjacent to her shoulder and collarbone and rotates between her left and right shoulder; Had a painful shoulder where injection side was on the left arm side back in the muscle down from the neck; Had a painful shoulder where injection side was on the left arm side back in the muscle down from the neck; Had a painful shoulder where injection side was on the left arm side back in the muscle down from the neck; Left shoulder was very painful; This is a spontaneous report from a contactable consumer (patient). A 66-years-old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, Formulation: Solution for injection, Lot number was unknown), via an unspecified route of administration, administered in Arm Left on 26Jan2021 (at the age of 66-years-old) as dose 1, single for covid-19 immunization at drug store with a grocery store, she clarified that it was a pharmacy in the store. Medical history included high blood pressure and diabetes from an unknown date and unknown if ongoing. Concomitant medications included amlodipine besylate taken for hypertension, chlortalidone 25mg taken for blood pressure, lisinopril and atorvastatin calcium taken for an unspecified indication, start and stop dates were not reported. Caller stated the vaccination facility where she received her vaccine did not provide her with a vaccination card or any information regarding the vaccine she received. Caller stated she went back to the facility where she received the vaccine, and they have no record of her first dose. Caller stated the day she received the first dose of the vaccine she was at the facility picking her usual prescriptions and there was a crowd of people lined up at the facility. Caller stated she asked what was the crowd of people there for and they said they were there for the COVID vaccine. Caller stated she asked if she was eligible to receive the vaccine and they told her yes. Caller would like to know how to get more information regarding how to schedule for second dose of the vaccine. Caller stated after receiving the injection her left shoulder was very painful for four days and she had to use an ice pack. Caller stated the pain was located adjacent to her shoulder and collarbone and rotates between her left and right shoulder. Caller stated the pain comes and goes. Caller stated today she was also experiencing a headache. Caller stated today was also the first time she had been able to raise her hand to her hip. Caller stated she walks 8 miles a day. Caller was extremely frustrated. She was calling about the Pfizer Covid Vaccine. She was a person of color. Quite a few people of color, are cautious of injections because of past history. She was a person a color, we have now come further than this. She goes a drug store because she had 3 medications that she would pick up from there. She got in there and seen huge line of people to come in and get this vaccine, she asked was this for the covid vaccine, they said yes, she asked which on was it for, they told her it was Pfizer. She waited for 4 hours to get the vaccine, that was not the problem, she was retired she does not mind the wait. After getting the shot, they gave her nothing, no information, no vaccine card, absolutely nothing, she tried to talk to the manager day and night, she had gotten nothing. Caller continuously asked if this agent could give her information about what Lot number, specific name of the vaccine that she received. Caller was informed multiple times to refer back to the facility. Caller was still upset, caller was informed that Pfizer was a drug manufacture and distributes the product but she would have to refer to facility for where she got the vaccine administered for further questions. Caller was upset that Pfizer does not have a database of names and vaccine given. Caller responds that she had already done that, she had been on the phone with store manager, the manager just said that their vaccine roll out was different. Caller stated that she got the vaccine in the store, they gave her the vaccine. Caller states that in the past when they gave her vaccine, most of the time it was at schools, but even they would give a card with documentation with a date and time and when to come back. Caller asked does the vaccine come in two doses. She does not even know when she would go back for the second. Caller stated that she had side effects and all that. She had a painful shoulder. Her brother was doctor and even he got information after his vaccine. She really hurts. She explained that after the first dose on 26Jan2021, she had a painful shoulder where injection side was on the left arm side back in the muscle down from the neck, like in the nape of the shoulder an inch or 2. It was not as painful today as it was before. The patient underwent lab tests and procedures which included when she got the first dose and was upset due to not having documentation, her doctor said come on in, we will look at that spot, and we would look to see for sure by taking a blood sample to see if she got the shot. They did take blood on 09Feb2021. Caller clarified saying that it was pain at the injection site. She was a pain tolerant person, she had 3 kids naturally, for this situation the injection site was quite painful, when it first took place, as night went on, she was just so grateful for her icepack, it was a flat ice pack, that got her though, today pain has moved to the level on the top shoulder where the indentation was, her pain was not sharp, but she could feel it, it was a 1 on the pain scale at the moment. Treatment received for events vaccination site pain, myalgia, neck pain and arthralgia. The outcome of events vaccination site pain, myalgia, neck pain, arthralgia was recovering, and events headache and pain was unknown.  Lot/batch number is not available despite the follow-up attempts made. Follow-up attempts have been completed and no further information is expected.