Age: 59.0
Sex: M
Vaccine: COVID19
Symptoms: Muscular weakness, Oedema peripheral, Pain in extremity, Peripheral swelling, SARS-CoV-2 test
Clinical narrative: Swollen left arm hand, shoulder and left breast; Swollen left arm hand, shoulder and left breast; Swollen left arm hand, shoulder and left breast; Swollen left arm hand, shoulder and left breast; Edema of left arm/hand, breast; Edema of left arm/hand, breast; Edema of left arm/hand, breast; pain at injection site; Pain in left arm/ Pain in left hand; Pain in left Shoulder; Weakness in left arm/ Still weakness in left arm with flexin and lifting objects of 5 plus lbs; pain in movement of arm and shoulder/Pain is still present in the deltoid arm at injection site with low ROM; pain and swelling in left chest; pain and swelling in left chest; This is a spontaneous report received from a contactable reporter(s) (Physician). The reporter is the patient.  A 59 year-old male patient received bnt162b2 (BNT162B2), intramuscular, administered in deltoid left, administration date 16Sep2021 10:30 (Lot number: EW0191) at the age of 59 years as dose 2, single for covid-19 immunisation. Relevant medical history included: "Ascending Pulmonary Aneurysm", start date: Nov2020 (unspecified if ongoing), notes: N/A monitoring every 6 hours; "Allergies: myosin" (unspecified if ongoing); "Allergies: sulfa" (unspecified if ongoing); "Allergies: Penicillin" (unspecified if ongoing). Concomitant medication(s) included: VITAMIN D3; METOPROLOL TARTRATE; AMLODIPINE BENAZEPRIL. Vaccination history included: Bnt162b2 (First Dose, Time: 10:00 AM, Route of administration-Intramuscular, Anatomical site: Left arm (Deltoid), Batch number: EW0176, Verbatim: Flu symptoms 2 days), administration date: 26Aug2021, when the patient was 59 years old, for COVID-19 Immunization, reaction(s): "Flu symptoms". The following information was reported: PERIPHERAL SWELLING (non-serious), PERIPHERAL SWELLING (non-serious), JOINT SWELLING (non-serious), BREAST SWELLING (non-serious) all with onset 17Sep2021 14:00, outcome "recovered with sequelae" and all described as "Swollen left arm hand, shoulder and left breast"; CHEST PAIN (non-serious), SWELLING (non-serious) all with onset 2021, outcome "unknown" and all described as "pain and swelling in left chest"; PAIN IN EXTREMITY (non-serious) with onset 17Sep2021, outcome "unknown", described as "Pain in left arm/ Pain in left hand"; ARTHRALGIA (non-serious) with onset 2021, outcome "unknown", described as "Pain in left Shoulder"; MUSCULAR WEAKNESS (non-serious) with onset 2021, outcome "not recovered", described as "Weakness in left arm/ Still weakness in left arm with flexin and lifting objects of 5 plus lbs"; OEDEMA PERIPHERAL (non-serious), BREAST OEDEMA (non-serious), OEDEMA PERIPHERAL (non-serious) all with onset 17Sep2021, outcome "recovered" and all described as "Edema of left arm/hand, breast"; VACCINATION SITE PAIN (non-serious) with onset 17Sep2021, outcome "not recovered", described as "pain at injection site"; VACCINATION SITE MOVEMENT IMPAIRMENT (non-serious) with onset 2021, outcome "not recovered", described as "pain in movement of arm and shoulder/Pain is still present in the deltoid arm at injection site with low ROM". Relevant laboratory tests and procedures are available in the appropriate section. Therapeutic measures were not taken as a result of peripheral swelling, peripheral swelling, joint swelling, breast swelling.  Clinical course: New event of edema of left arm/hand, breast, pain at injection site, pain in movement of arm and shoulder/Pain is still present in the deltoid arm at injection site with low ROM. Edema of left arm/hand, breast. Disuse of left arm, 4 months with pain. Patient stated that I received the 2nd vaccine. On the next day, soreness in left arm, accompany with edema of left arm, breast and hand with pain in movement of arm and shoulder. Also pain at injection site. The edema lasted nearly 3 weeks. Pain is still present in the deltoid arm at injection site with low ROM.  Additional information: Facility where the most recent COVID-19 vaccine was administered: Hospital. Prior to vaccination, was the patient diagnosed with COVID-19?:No. Since the vaccination, has the patient been tested for COVID-19?:Yes  No follow-up attempts are possible. No further information is expected.