Age: 59.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Malaise, Memory impairment, Nausea, Pain, Pain in extremity
Clinical narrative: weak; blood pressure (BP) and it was 131/104, her pulse was 104; cognitive problems/forgetting words/forget what she was going to say it would take a while, like a brain fog; forgetting words/forget what she was going to say it would take a while, like a brain fog; she would forget what she was doing; she felt unwell; she was wheezing a bit; exhaustion; cough; body aches/bad pain; pain in all of her left arm where she got the injection; pain in the left side of chest; her heart was hurting; her heart was really pounding, like she was in a race/pulse was 104; her temperature it was not too high, it was 99.5 so not over 100; very severe headache with dizziness; nausea; very severe headache with dizziness; she could not fall asleep; pre-existing condition (chronic motility issues) got worse; pre-existing condition (chronic motility issues) got worse; upset stomach; severe abdominal pain; This is a spontaneous report from a contactable consumer (who is also the patient). A 59-year-old female patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, lot number: EW0170), via an unspecified route of administration, on 16Apr2021, as 1st dose, single, for COVID-19 immunisation. Medical history included hypotension from an unspecified date, and chronic motility issues from 2017 and ongoing. The patient's concomitant medications were not reported. On 16Apr2021, the patient received the first dose of BNT162B2 and got slightly dizzy immediately after the vaccine. Her arm did not hurt, and she was okay until she went home. She had nausea and headache. She went to sleep and woke up after 12 midnight (17Apr2021) with a really bad headache and her heart was pounding like she was in a race. She also had pain in all of her left arm where she got the injection, body aches and pain in the left side of chest, like her heart was hurting. She checked her temperature it was not too high; it was 99.5 so not over 100. She took Tylenol 100 mg. She woke up at 2:00 and still had headache. It took all night to help her headache and she took another Tylenol 500 mg. When she woke up next morning, she still had a headache but not as severe. She thought okay this is going to be the usual thing and go away in a couple of days. She reported that from 16Apr2021, she could not fall asleep and would get a headache which got worse as she was not falling asleep. On 17Apr2021 and 18Apr2021, the patient experienced really bad pain, her arm was hurting, and she kept taking Tylenol. On 18Apr2021, she started coughing so she took Robitussin for the cough. On the same day, 18Apr2021, she had body aches, nausea and was exhausted. She mentioned that she is a very active person, an avid cyclist, and normally walks 10 miles, but when she walked a couple of miles, she was exhausted and could not do anything else. It was very difficult for her and it was unusual. She was still experiencing the events on 19Apr2021 and 20Apr2021. So, on 21Apr2021, she went to her primary care physician's office but saw another doctor who was available that day. The doctor checked if her legs were swollen and checked her lungs. The doctor stated the patient was wheezing a bit but did not see anything else. The doctor advised her not to take the second dose. The patient mentioned that her pre-existing condition (chronic motility issues) got worse. In Apr2021, experienced upset stomach, severe abdominal pain. On 22Apr2021, she woke up and felt totally fine. She thought the symptoms were finally going away. But at 17:00, she felt unwell, had body pain, headache, and she was coughing again. She went to sleep and woke up on 23Apr2021 at 04:30. She woke up with a severe headache, extreme nausea (no vomiting), was really weak, dizzy, absolutely exhausted. She still had exhaustion, nausea, body aches, and cough. She checked her blood pressure (BP) and it was 131/104, her pulse was 104. She took Tylenol 1000 mg and the symptoms did not go away so she took another Tylenol 500 mg. After an hour, her headache was not better, dizziness was bad, but her BP was going down. She called the nurse line and was advised to go to the ER. At the ER, she was given IV fluids to hydrate and pain medications. She was then tested for COVID-19 which came back negative. The patient also had cognitive problems. By the time she got to the ER, she was forgetting words (she would try to say something and she would forget what she was going to say it would take a while, like a brain fog) and she would forget what she was doing. She would catch herself forgetting and not remembering words. The patient wanted to know if she should get the second dose, how long should she wait until she gets her second dose, how long do the side effects last, will the side effects from the second dose be worse, how the vaccine works, asked the ingredients of the vaccine, and asked if there is a need for a third dose. The patient assessed the events dizziness, nausea, headache, pain in arm, chest pain, fatigue, body aches/bad pain and cough as serious (medically significant). The patient was recovering from dizziness, headache, body aches/bad pain, hypertension, cognitive disorder, aphasia and memory impairment. The outcome of the events nausea, fatigue, and cough was not recovered. The outcome of the remaining events was unknown.