Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Lethargy, Myalgia, Near death experience, Neck pain, Pain
Clinical narrative: He states he sometimes has chills, and said that he can be sitting outside on a 90 degree day and feels like he is freezing to death; His arm was a little sore for a day; Caller states he just got lethargic; He just doesn't feel normal, like he did prior to getting the shots.  He states he just feels different; He said that the injection site was sore; He is having a lot of muscle and joint pain; He is having a lot of muscle and joint pain/Caller states that his joints hurt; wrists, ankles, elbows/Mostly in his neck and shoulders that hasn't gone away.; Mostly in his neck and shoulders that hasn't gone away; He also has a low-grade headache; He states he sometimes has chills, and said that he can be sitting outside on a 90 degree day and feels like he is freezing to death; Tired all the time; Upper body pain; This is a spontaneous report from a contactable consumer or other non hcp. A 72-years-old male patient received bnt162b2 (PFIZER-BIONTECH COVID-19 VACCINE, Formulation: Solution for injection, Batch/Lot Number: ER8734), dose 1 via an unspecified route of administration, administered in Arm Left on 31Mar2021 as dose 1, single for covid-19 immunisation. Medical history included ongoing arthritis in lower back started about 40 years ago, ongoing COPD Started about 15 years ago and it may have been before then, Open heart surgery from Oct2005. He did not have a heart attack. He was walking 5-6 miles a day. They found a problem after his stress test, tobacco user, Smokes about a pack a day. He started in his late 30s, maybe at 38 years old, allergic to dust mites, hip surgery, had a lot of surgeries, he has rods in his back and two artificial hips, sinus infection two or three times per year with discolored mucus and a low key headache. The patient reported that he gets a flu shot every year from the VA. He said that sometimes he does not have any arm pain from it and sometimes he does. The patient has had a lot of surgeries, he has rods in his back and two artificial hips. He usually has a sinus infection two or three times per year with discolored mucus and a low key headache. Family history included, Arthritis and joint problems. Arthritis and joint problems which came on in their elderly years. prior vaccinations the patient had no event other than the occasional sore arm where they gave him the shot. Patient was not obese. The patient's concomitant medications were not reported. On 02Apr2021, the patient experienced he states he sometimes has chills, and said that he can be sitting outside on a 90 degree day and feels like he is freezing to death, his arm was a little sore for a day, caller states he just got lethargic, he just doesn't feel normal, like he did prior to getting the shots. he states he just feels different, he said that the injection site was sore, he is having a lot of muscle and joint pain, He is having a lot of muscle and joint pain/Caller states that his joints hurt; wrists, ankles, elbows/Mostly in his neck and shoulders that hasn't gone away, he also has a low-grade headache, he states he sometimes has chills, and said that he can be sitting outside on a 90 degree day and feels like he is freezing to death, tired all the time, upper body pain. It was reported that the patient got the vaccinations at (withheld) and was told if he had any side effects that he should call. He states that he just wanted to report the side effects like he was asked to do. Caller stated that he goes to the doctor in (withheld). He stated that he was 100% disabled veteran. The patient has been tired all the time since about the third day after getting his first vaccine on 31Mar2021. He has waited 3 months to report this, he was thinking it might subside. He did not have any problems with the injections other than his arm was a little sore for a day. He just got lethargic and just got tired and it has not gone away. He doesn't feel sick, he just doesn't feel normal, like he did prior to getting the shots. He informed he just felt different. NDC number was unknown to patient. He said that the injection site was sore, and reported that he has had enough shots in his life to know that it can be the way the person gives the shot or how tense he is at the time it is given. He also has a low-grade headache, but said that it could be from the neck and shoulder pain, he did not know. The patient reported sometimes he has chills, and he can be sitting outside on a 90 degree day and feels like he is freezing to death, but he said he doesn't feel like he is dying, but he does not feel normal like he did prior to the shots. This is how his headache feels now. He reported his headache is not horrible, but he knows it is still there and Tylenol does help and keeps it in check. The patient stated that his muscle and joint pain and very low key headache are 24/7. Tylenol helps take the edge off. Chills just happen, sometimes at night, in the morning, or the afternoon. He just doesn't feel normal like he did prior to the vaccine but states he doesn't feel sick. The patient informed he had these symptoms one or two times before getting the vaccines but his neck, shoulder and upper body pain is the most constant and has noticed that more than anything. He used to never have neck and shoulder pain, just lower back and leg pain. His joints hurt; wrists, ankles, elbows. and he said it could be a coincidence and it could be his age and condition. He said that this may not be the vaccine but this has occurred since getting the vaccine. He informed that he does not live a really active life. He has had no testing since vaccination. He is still not ready to go to a hospital waiting room and sit. The patient informed that he has not mentioned this to his doctor yet. He has an appointment next month and will mention it to his doctor then. He is taking Tylenol for headaches which helps a little. Time of the Vaccination Was not given. Vaccine was not administered at military facility. No additional vaccines were administered on same date of the pfizer suspect. No adverse event caused emergency room or physician office visit. No other vaccinations were administered within four weeks prior to the first administration date of the suspect vaccine. The patient had no further questions. Outcome of the all events were unknown.