Age: 53.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Insomnia, Investigation, Major depression, Neck pain, Neurological examination
Clinical narrative: Major depressive disorder, single episode, unspecified/ depression; Anesthesia of skin; Radiculopathy, site unspecified; Generalized anxiety disorder/ anxiety/ always worrying/ scared and nervous; Insomnia, unspecified/ not sleeping well; cough; PTSD; tremors in hands; neck pain; pain both arms, from shoulders to thumbs intermittent, sharp, shooting/ sharp pain in my right arm; right & left arm numbness/ numbness in thumbs alternates sides, left worse than right, worse at night; weakness/ hands seem weak; This is a spontaneous report from a contactable consumer (patient). A 53-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration in right arm on 14Apr2021 11:00 (Batch/Lot Number: EW0153) at the age of 53 years, as dose 1, single for COVID-19 immunisation. Medical history included chickenpox (childhood illnesses: 1-2 years),hydronephrosis, renal mass in 2014, acne, post menopausal, anxiety, constipation, kidney stones, ovarian cyst removal in Apr2000, renal surgery (2 failed pyeloplasties; hydronephrosis; clip removal- right kidney), wisdom tooth extraction in 1984, renal stent (multiple stents: 13), ovarian surgery in 2007 (right ovary removed), liposuction in 2012 (elective), kidney stone in 2019, wears assistive devices: glasses, parity 3 (full term). Patient had healthy well balanced diet, typically sleeps 6 hours a night. She was a former cigarette smoker/ tobacco use (quit on 01Jan2016, quit smoking - age 48 years, started smoking - age 26 years), denied drug use, had daily caffeine (consumes on average 2 cups of coffee per day), negative for energy drinks, green tea, iced tea. She exercises daily (twice a day 30min daily during the week). She uses sunscreen (history of sunburns prior to age 18). Family was negative for colon cancer. Patient's mother had hypothyroidism; brother and sister had hypothyroidism and diabetes mellitus II. The patient previously took ciprofloxacin (CIPRO) and experienced allergies. The patient previously received influenza vaccine (FLUZONE) (ages 6 mos - 17 yrs), Adacel, Boostrix - Tdap on 01Jan2012. Concomitant medications included gabapentin taken for an unspecified indication, furosemide taken for an unspecified indication, docusate sodium (STOOL SOFTENER) taken for an unspecified indication, alprazolam taken for anxiety, ibuprofen taken for an unspecified indication; sulfamethoxazole, trimethoprim (BACTRIM DS) taken for an unspecified indication, cefuroxime axetil (CEFUROXIME AXETIL ZHIJUN) taken for an unspecified indication, prednisone taken for an unspecified indication, and tretinoin (RETIN-A) taken for an unspecified indication; start and stop dates were not reported. The patient complained of right & left arm numbness, pain and weakness. The symptoms started 2 weeks later (21Apr2021). Within 2 weeks of the first vaccine, she developed sharp pain in her right arm and numbness in her arms and no feeling in her right thumb. The shooting pain was unbearable. She went to her primary care doctor's office. They gave her a referral to have a EMG w/nerve conduct study. Her insurance company advised me. She would have to payout of my pocket for this test. She was unable to pay for this test. The patient denied any injury or fall. Events were reported as 'important medical event.' The patient experienced pain both arms, from shoulders to thumbs, intermittent, sharp, shooting, some numbness in thumbs alternates sides, left worse than right, worse at night, wakes her from sleep, hands seem weak, had tremors in hands that lasted less than 1 minute. The patient stated that ibuprofen (ADVIL) takes the edge off, but symptoms seemed to be worsening. Paracetamol (TYLENOL) did not help. The symptoms have never occurred before. She had some neck pain, not significant; but denied chest pain or sob (shortness of breath), no vision changes or slurred speech, no known in jury. The symptoms started approximately 1 week after getting vaccine. On 05May2021, patient's BP Right Sitting was 110/80, BP Left Sitting was 110/80, BMI: 26.6, Pulse: 78, Resp: 16, 02Sat: 98, and T: 98.0. Examinations included: Const: Appears healthy, well developed, well hydrated, well nourished, well groomed and pleasant. NO signs of acute distress present. Eyes: Conjunctivae: Clear. Pupils equal, round and reactive to light. Sclerae were white and without lesions. ENMT: External ears WNL. External canals were clear and dry. Tympanic membranes translucent, with good landmarks bilaterally. External nose exhibits no deformity, discoloration or lesions. Moistness and normal color of the nasal mucosas. Oropharynx: Appears normal. Neck: Normally curved, supple and symmetric on inspection. Thyroid exhibits no nodules or thyromegaly. Resp: Inspection of chest reveals symmetrical thorax and normal musculature. Chest expansion was symmetric. Respirations were regular and unlabored. Respiration rate was normal, Auscultate good airflow. No diminished sound, crackles, rhonchi, rub or wheezes over the lungs bilaterally. Voice resonance was clear. CV: Rate was within normal range. Rhythm was regular. Sl and S2 were normal, No heart murmur appreciated, radial, ulnar, and brachial pulses present and wnl bilaterally. Musculo: Upper Extremities: Tone, temperature, color, and bulk were symmetric. Strength: 5/5 bilaterally. Full ROM bilaterally. Lower Extremities: Tone, temperature, color and bulk were symmetric. Strength: 5/5 bilaterally. Full ROM Bilaterally neck with from, no pain with palpation, no pain to bilateral upper traps or shoulders. Neuro: Alert and oriented x3. Mood was normal. Affect was normal. Memory was intact. Attentive. Speech iwa articulate and fluent. Reflexes: upper extremity reflexes are intact and upper extremity reflexes are symmetric bilaterally. Prior weight was 1551b as of 01Oct2020. Symptoms for 6 weeks, on an unspecified date included: consistently thinks due to daughter's medical situation (daughter was paralyzed by COVID vaccine), crying, not sleeping well, she had anxiety and depression and symptoms increased since her daughter had been sick. She tried sertraline (ZOLOFT), escitalopram (LEXAPRO), and bupropion (WELLBUTRIN) in the past. Patient also reported flu anxiety and insomnia. Patient was prescribed benzonatate (TSSALON Perles 100 mg) 1 by mouth every 8 hour as needed for cough, discontinue amoxicillin 500 mg I by mouth three times a day x 10 days. She was taking trazadone for sleep  which had been effective the last few days. She denied side effects. She did not hear back regarding therapy and was still interested in pursuing taking alprazolam (XANAX PM). She rarely had intermittent pain/numbness right thumb. EMG was ordered in May but was not covered by insurance. Patient planned to consult with flu specialist. Patient's assessment included: R20.O Anesthesia of skin which was treat with prednisone taper to decrease (EMG w/Nerve Conduct Study, Upper was ordered); Pain in arm, unspecified; M54.IO Radiculopathy, site unspecified prescribed with gabapentin (follow-up in 1 week); F41.1 Generalized anxiety disorder - stable, treated with alprazolam (XANAX) prn; F32.9 Major depressive disorder, single episode, unspecified; G47.OO Insomnia, unspecified - improved with trazodone. The patient denied constitutional, cardiovascular, respiratory, gastrointestinal, and musculoskeletal symptoms; also denied urinary problems. As of 29Sep2021, patient stated "I still do not have feeling in my right thumb and still get shooting pain that stops me in my tracks. I am now suffering from PTSD. I did all the motions during this time and now suffering from stress, lack of sleep and always worrying about my daughter. I will never be the same. We just wanted to concentrate on doing what we can to get her healthy, once all the craziness settled I cannot stop waxing up scared and nervous my anxiety is so bad." Patient was still having sharp pains in arm, no feeling in thumb. Outcome of 'pain both arms, from shoulders to thumbs intermittent, sharp, shooting/ sharp pain in my right arm,' 'right & left arm numbness/ numbness in thumbs alternates sides, left worse than right, worse at night,' and 'weakness/ hands seem weak' was recovering; of all remaining events was unknown.   Follow-up attempts are completed. No further information is expected.