Age: 52.0
Sex: F
Vaccine: COVID19
Symptoms: Pain, Pain assessment, Pain in extremity, Spinal pain, Tremor
Clinical narrative: high level of shortness of breath; Diarrhea; spinal column hurt the worst (the spine from the top of her neck to her butt); butt muscles hurt really bad; caller's spinal column hurt the worst, the front of her calves and hip joints; spinal column hurt the worst, the very edges of her back, the side of her back was excruciating; Dizziness; Vomiting; not feeling well enough; shaking; shivering/ chills; pulse ox and it dropped down to 93; Excruciating body pain; Headache; sore arm / front of her calves, front of her thighs, left arm, 3 left fingers; Exhaustion; no appetite at all; This is a spontaneous report from a contactable consumer, the patient. A 52-year-old female patient received the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 MRNA VACCINE; Lot number: unknown), via an unspecified route of administration in the left arm on 08Mar2021 at 10:15 (at the age of 52-years-old) as a single dose for COVID-19 immunization. Medical history included ongoing epilepsy since Oct2015 (officially diagnosed in Oct2015, but the doctors believed it was in her early 20s but she was misdiagnosed for decades), post-traumatic stress disorder (PTSD) from 2020 (diagnosed a year ago), sleep apnea since 2016 (patient thought she was diagnosed in 2016), COVID-19 in Nov2020 from which the patient almost died, memory loss (left over COVID symptom) for which the patient was in speech therapy, intermittent body pain (aftereffects of COVID-19), relapse in seizures due to COVID-19, her eyesight was terrible, epilepsy migraines. Concomitant medications included unspecified epilepsy medications. There was no other vaccine given on the same day, or 4 weeks prior to the vaccination. The patient previously received a flu shot and fainted, on an unspecified date. On 08Mar2021 at 11:15, the patient experienced sore arm (pain 2/10). On 08Mar2021 at 22:00, the patient had headache which got progressively worse, then it got so bad she wanted to pop her head off at midnight. On 09Mar2021 at 00:00, the patient had shaking and shivering where it looked like she was convulsing (she had history of epilepsy and knew what a seizure felt like, her husband may have thought she was having a seizure). The patient had chills to the point where she had multiple blankets and could not stop shaking, took her pulse ox and it dropped down to 93. The caller's baseline temperature was 97.1 and her daughter took her temperature and it was 98.9, most people wouldn't consider that a temperature, but it was a temperature for her. The caller kept shaking like that for hours. On 09Mar2021 between 21:00-23:00, the patient had chills again. On 09Mar2021, the patient experienced excruciating body pain (pain 9/10) in very specific parts of her body. On 09Mar2021 by 12:00, the caller's spinal column hurt the worst, the front of her calves and hip joints, the very edges of her back, the spine from the top of her neck to her butt and then next to it was not so bad but the side of her back was excruciating, the butt muscles hurt really bad, the front of her thighs, left arm, 3 left fingers, but not the other 2 fingers. Oddly enough, she was considered a long hauler, it was the places that her occupational therapist and physical therapists were working on. On 09Mar2021 at 00:00, the patient experienced dizziness (that was on and off all day until bedtime last night on 09Mar2021) and vomiting (she couldn't hold down water). On 09Mar2021, the patient was not feeling well enough. On 10Mar2021 at 08:00, the patient experienced diarrhea (she's only gone to the bathroom twice). On Mar2021, the patient experienced exhaustion and no appetite at all. On an unspecified date, the patient experienced a high level of shortness of breath (patient was unsure if this was due to COVID-19). The patient underwent laboratory tests and procedures which included an echocardiogram on an unspecified date: her left atrium was enlarged and her cardiac numbers were high, they were going to monitor her heart and the doctors didn't know if it was because she had COVID-19 or if it was that the doctors got lucky and found it, they had nothing to compare it to because she only had this one echocardiogram. The patient had history of epilepsy migraines (can pinpoint the spot where it hurts), she thought she would try sumatriptan succinate (IMITREX) for this headache (her whole head hurt), as it didn't interact with her other medications. The patient also took acetaminophen/diphenhydramine (TYLENOL PM; Lot: GF6062, Expiry: Jun2022), ibuprofen (patient thinks the Lot is QWE2546A, but is unsure) for the headache. The patient took ondansetron (ZOFRAN) which she had from a previous prescription and that made the vomiting stop. The events did not require an emergency room or physician office visit. The patient did not think that the reactions were due to her epilepsy medication. The clinical outcome of excruciating body pain was resolved on 09Mar2021 (it's hard for the caller to say if she has recovered because she had COVID-19 aftereffects and had body pains that come back intermittently), sore arm / front of her calves, front of her thighs, left arm, 3 left fingers, shaking, shivering/chills, pulse ox and it dropped down to 93, spinal column hurt the worst (the spine from the top of her neck to her butt), butt muscles hurt really bad, caller's spinal column hurt the worst, the front of her calves and hip joints, spinal column hurt the worst, the very edges of her back, the side of her back was excruciating, dizziness, vomiting, not feeling well enough,  no appetite at all was resolved on 09Mar2021; headache was not resolved (unless the caller was asleep, she felt the headache); exhaustion was not resolved; diarrhea and high level of shortness of breath was unknown.   Information on the lot/batch number has been requested.