Age: 95.0
Sex: F
Vaccine: COVID19
Symptoms: Chills, Cough, Dyspnoea, Gait disturbance, Malaise
Clinical narrative: can barely walk; upper respiratory problems; Sinus infection; has not been well/ bad shape/ can't be out of bed for 2 seconds with out having to get back into bed/ wasn't feeling good/ not feeling well; chills; fever as high as 104.5; nasal congestion; upper respiratory difficulty breathing/ can't breathe through her nose; non-productive cough; breathing rapid; Arm pain/ sore arm around the injection site; This is a spontaneous report from a contactable consumer (Caregiver/ Patient's daughter). A 95-year-old female patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE), via an unspecified route of administration on 26Mar2021 14:00 (Batch/Lot number was not reported) as a single dose for COVID-19 immunisation. The patient medical history and concomitant medications were not reported. The patient previously received her first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE) on 02Mar2021. The patient was reported to have possible side effects that was getting worse. The patient had "chills, fever, nasal congestion, upper respiratory difficulty breathing, non-productive cough." On Monday evening, 29Mar2021, the patient was brought to the hospital but tests showed that "everything looked good" (chest x-ray etc.) Last night, the patient's temperature reached 104 F and was given paracetamol (TYLENOL). The patient mentioned that she was "breathing rapid," and that she "coughs when she takes a breath." Reporter asked if patient can be given an antihistamine; or something to help with the upper respiratory concern (nose blockage, upper respiratory breathing). The patient had not been well. They spent Monday evening and all night and in the morning at the hospital. They did X-rays and lab work and everything else. The doctors couldn't find anything wrong with her and stated that it's got to be the vaccine. She was really in bad shape at this point. She can't be out of bed for 2 seconds without having to get back into bed. She was having a upper respiratory thing going on. She had a fever as high as 104.5 last night. The fever was last night and she got paracetamol (TYLENOL) for that and brought it down. It did respond. The patient stated she can't breathe through her nose and she has upper respiratory problems. The problem was when they went to the hospital, they didn't find signs of infections, all normal across the board. The patient doesn't fake it, she was a feisty elderly lady. She walks up the hill every day. She was independent. Normally, she can walk and walks very well without any assistance. The patient now can barely walk. She can barely walk to the toilet without holding on to anything. She was constantly complaining about chills. Reporter wanted to know what can they do and not do and what should the doctors be looking at. They kind of just threw up their hands as this was side effects of the vaccine, but the patient was alarming on Monday night and even more alarming right now. The patient was in bad shape. She wasn't feeling good on Saturday night, but not too bad on Friday night. Reporter asked her mom how she felt on Friday. Reporter told her mom to put in her hearing aids, that would probably help. Reporter further explained that patient had a sore arm around the injection site and that she might not have been feeling that great. On Saturday, she was not feeling well and started to have a fever, sinus infection and upper respiratory problems. The patient stated that she finally identified it. Reporter confirmed the fever, sinus infection, and upper respiratory problems started on 27Mar2021 towards the late afternoon she was  progressively getting worse. Fever, sinus infection, chills, upper respiratory problems all have worsened. The reporter stated that her mother's (patient's) arm pain got better on Sunday and was now gone. On Saturday, her arm hurt from her shoulder to her elbow, it did get worse. However, a the next day it was gone pretty much. Monday in the emergency room, they did labs for her kidney, liver and were looking for infection. They did not find anything came up normal on everything. Today, the reporter thinks patient was worse. She doesn't want to come out of bed at all. She was laying there like a lump, whining and crying which she has never done. She was probably going to take her to the hospital again and  they were not going to do anything again. She stated that something got to change, They haven't had that conversation about going to the hospital. She was going to go downhill if this continues, it had gone downhill at this point. Reporter confirmed that patient has recovered completely from the arm pain while outcome of remaining events was not recovered.   Information about the lot/batch number has been requested.