Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Haemoglobin, Headache, Investigation, Pain in extremity
Clinical narrative: Dizzy; Blood pressure systolic high; headache; extremely tired; sore arm; This is a spontaneous report from a contactable consumer (Patient) via Medical Information Team. A 71-year-old female patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, Formulation: Solution for injection, Lot number: EL1284 Expiry date: 01Apr2021), via an unspecified route of administration, administered in right arm on 28Jan2021 around 03:30 PM (at the age of 71-years), as a single dose for COVID-19 immunisation. The patient got her COVID-19 Vaccine in her right arm because she had her lymph nodes removed on her left side due to left-sided breast cancer.   Medical history included Seizure (She had a seizure at age 6, again at 12, both times she was told that seizures were because of a high fever. She said she was given phenobarbital at the time. She said her tests always showed something was abnormal. She said her next seizure was in her 40s and she had an MRI, and nothing was there. Patient was started on medicine and sent to a neurologist. Patient said she went through lots of medicines and either had a reaction, or the medicine did not control her seizures. In 1998 seizure at her doctor office, and the doctor had to do CPR on her, and then had an ambulance taken her to the emergency room. Patient had a vagal nerve stimulator implanted for seizure control in 1998 and she has a lead that goes to her head and neck, and a battery in her right shoulder). Stroke (In 12Feb2002 that was caused by hormone medicine & seizure medicine that interacted with each other at 52 years old and was hospitalized for 4 months, needing physical therapy, speech therapy, and a couple other types of therapy), Total hysterectomy (in Dec2001, she was started on a hormone pill after her total hysterectomy and hormone pill interacted with a seizure medicine she was taking at the same time, and caused her to have a major stroke on 12Feb2002), Diabetes (2009), TIA (2009), Left-sided breast cancer (From Dec2015 and will make a decision to continue with cancer medicine, anastrozole 1mg takes at supper. Mfg. Zydus Pharmacy NDC: 68382-209-06, GTIN: 00368382209061, SN: 30100085636501, Lot: M009071, Exp: 30Jun2022), Lymphadenectomy, patient had unspecified allergies in the past from medicines and ongoing triglycerides that are out of the ballpark. Patient got her regular flu shot in either Oct2020 or Nov2020.   The patient concomitant medications included Anastrozole, Jaediance, Vascepa and Prolia. Patient was taking Jardiance 10mg pill once in the morning at breakfast, for about 2 years, dispensed in a (Pharmacy Name Withheld) pharmacy bottle with no NDC, Lot, and Expiration Date, and the manufacturer is listed as Boehringer Ing on the prescription label. Patient was taking Vascepa 1gm capsule at dinner time daily, and after 3 months of taking Vascepa, her triglycerides are down to 190. She said she started Vascepa 1gram capsules about 1 to 1-1/2 years ago that was dispensed in a (Pharmacy Name Withheld) pharmacy bottle with no NDC, Lot and Expiration Date. She said the manufacturer is Amarin Pharma 1 as listed on the Vascepa 1gram prescription label. Patient couldn't take 2 Vascepa 1gram capsules because she was in too much pain. Patient was taking Prolia injection done twice a year from three years at her doctor office for osteoporosis.   On 28Jan2021 (same day of vaccination), patient was immediately dizzy, sat down and the room was spinning, they checked BP and it was up to 180, unknown what was bottom number. They moved me to a separate room and continued to check my BP. Patient walked with a nurse to another chair, and the nurse checked back with her after 5 minutes, and she got even worse. The nurse checked her blood pressure on her right arm, and her top blood pressure number had jumped to 180. Later moved to a private room with a recliner where nurse continued to monitor her every few minutes. Nurse called an emergency room doctor around 3:30PM to see if she needed to be transferred to the hospital emergency room. The emergency room doctor told the nurse to continue monitoring her where she was, and as long as her blood pressure did not go any higher, or nothing else happened, she could go home. Patient blood pressure went down to 130 and she was released from the COVID-19 Vaccine waiting area at 5:30PM. Patient experienced a headache and was extremely tired and had a sore arm. Patient spoke to one of her doctors and they mentioned having the Moderna vaccine for her second dose and one of her doctors told her to take the second COVID-19 Vaccine dose, while another doctor told her not to get the second COVID-19 Vaccine dose. Patient asked if she should get her second vaccine dose if she experienced a reaction to the first also if her BP will go up again with the second vaccine dose because she was afraid it will do it again and asks whether she should take the Moderna instead. Patient asked if she still need to stay away from my new grandson, should wait 21 days after first dose, and should still wear a mask or she was protected. Patient stated that according to nurse, she was only the second person to have that kind of reaction. Patient informed nurse that she was diabetic, but she does not take insulin. She said her last Hemoglobin A1C was 6.4. Patient wanted to visit a cardiologist because she has a big family history of heart problems and though never had a heart attack, but she is always concerned because her triglycerides are out of the ballpark. She clarified that a normal triglyceride level is 150 and her triglycerides were staying over 300. Patient lab tests included blood pressure (180, later came down to 130), triglycerides (over 300) on 28Jan2021, cholesterol and Haemoglobin (6.4) on an unspecified date. The patient did not take any other vaccine on that same day, as well as four weeks prior vaccination. The patient had hoped to get the Moderna COVID-19 Vaccine. She said her primary care doctor told her to take the Moderna COVID-19 Vaccine, but she couldn't find anyone who she could register with. The outcome of the events dizziness and systolic blood pressure increased was recovered for and unknown for all other events.