Age: 34.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, Feeling abnormal, Joint range of motion decreased, Muscle spasms, Neck pain
Clinical narrative: Shoulder pain; Her arm, left arm where she got the shot, started hurting so bad/could not even use her arm; Pain was shooting into her neck; Pain was like nerve pain; it felt like she had a nerve issue or had a really bad Charlie horse that would not let go; she was in tears; if she touched her fingers together with her thumb it would make her shoulder tense up and not a muscle spasm; Her arm, left arm where she got the shot, started hurting so bad/could not even use her arm; This is a spontaneous report from a contactable consumer (patient) via medical information team. A 34-year-old female patient received BNT162b2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, Formulation: Solution for injection, Batch/Lot Number: EW0169; Expiration Date: Aug2021), via an unspecified route of administration in left arm on 22Apr2021 at 13:00 (at the age of 34-year-old) as dose 2, single for COVID-19 immunisation. Medical history included breast cyst from 2020 and ongoing, ongoing depression (diagnosed in early 2000s, so 2005 or 2006), breast operation (breast cyst: she had removed it) from 29Apr2021 to 29Apr2021. Concomitant medication(s) included sulfamethoxazole (Sulfameth) taken for breast cyst, start and stop date were not reported; cefalexin (CEPHALEXINE) taken for breast cyst from 31Mar2021 to Apr2021 (for a week, 500mg, two times a day. Caller unsure of LOT, NDC, Expiry date. Caller stated it was a prescription, prescribed on 31Mar2021 and says to use before 31Mar2022); sertraline taken for antidepressant therapy from an unspecified start date and ongoing; ethinylestradiol, levonorgestrel (KURVELO) taken for contraception, start and stop date were not reported (it popped up late 2020 and she went to her gynecologist and while was giving the exam, caller asked what it might be, and the gynecologist said it was a cyst. Caller states she had it removed yesterday), steroid shot, steroid ointment taken for breast cyst, start and stop date were not reported, 6 shots of numbing solution taken for breast cyst, from 29Apr2021 and stop date was not reported. The patient previously took BNT162b2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, Formulation: Solution for injection, Batch/Lot Number: ER8734; Expiration Date: Jul2021), via an unspecified route of administration in left arm on 01Apr2021 at 11:00 (at the age of 34-year-old) as dose 1, single for COVID-19 immunisation. The patient did not receive any other vaccines within four weeks prior to the vaccination. Caller stated she got her second Pfizer shot Thursday of last week and in the middle of the night, maybe around 12, she started having some shoulder pain. Caller stated she thought, no big deal. Caller stated the next day, the pain started getting worse and worse throughout the day to the point that she could not lift her arm without pain shooting up and down into her left arm into her neck, felt like nerve pain. Caller stated it felt like she had a nerve issue or had a really bad Charlie horse that would not let go. Caller stated it was gotten a little bit better where she can lift her arm now, but she still feels it. Caller stated it was a dull pain, constantly and it has been over a week. Caller stated she did not know if she should be concerned or if she should just wait and see if it goes away. Started feeling mild shoulder pain. Caller stated she did not even have pain in the injection when she first got it. Caller stated she had mild shoulder pain on Friday morning at 01:00 about 12 hours after. Caller stated it gradually got worse, but not to the point where it was taking her breath away. Caller stated now, she can actually lift her arm, but it was a dull, constant pain. Caller stated it started in the shoulder and moved to the neck then gradually went through the whole arm even to her fingers. Caller stated if she touched her fingers together with her thumb it would make her shoulder tense up and not a muscle spasm, but her muscle contracted where she could not control it until it loosened up. Caller stated it was really weird. Caller stated she did not know if the person who gave her the shot may have hit a nerve, that was her initial thing, and it was still going. Caller stated by 10:00, she was in tears. Could not lift her arm without pain shooting: caller stated her arm was better, but if she really presses her hands together, then she can still feel it. Caller verified all of her symptoms have improved. Caller stated if it helps, she was at a scale of 1 to 10, she was at a 9 and maybe she was at a 5 now. Caller stated her husband was the one who had his hands on the vaccine cards last. Pfizer Covid Vaccine: First Dose: Caller states received first dose on 01Apr2021. Caller provides LOT: ER8734, Expiry Date: Jul2021. Caller unsure of dosage given or NDC. Caller verifies it was an injection in her left arm. Caller stated she received it around 11:00 in the morning. Pfizer Covid Vaccine: Second Dose: Caller states she received the second dose on 22Apr2021. Caller provides LOT: EW0169, Expiry Date: Aug2021. Caller unsure of NDC, or dosage given. Caller verifies it was an injection and given in her left arm at 13:00 in the afternoon. Caller stated she works, she was a teaching artist with theatre, and she goes in elementary schools. Caller stated she knew she would be around children in the future and just to be safe, so she does not get it and cannot spread it to other people. Caller stated she has been taking antibiotics. Caller states she started taking them right before the first shot, so the last day of March, literally the day before, for a cyst in her breast. Caller stated she got put on a second antibiotic for two weeks, she just got off it about a week ago. Caller stated she also got a steroid shot in her breast for the cyst. Caller stated she had the cyst removed yesterday and she had 6 shots of numbing solution injected into her breast. Caller stated the steroid shot was terrible. Caller unsure of what the steroid shot was called. Sulfamethoxazole: Caller stated the most recent antibiotic was Sulfameth, verified as Sulfamethoxazole. Caller stated she takes it three times a day, by mouth and the dosage is 800/160mg. Cephalexin: Caller stated the first prescription of antibiotics was Cephalexin for a week, 500mg, two times a day. Caller unsure of LOT, NDC, Expiry date. Caller states it was a prescription, prescribed on 31Mar2021 and says to use before 31Mar2022. Caller verifies it is in a brown bottle from the pharmacy. Caller states what happened was the cyst got infected and she went to her primary care doctor because the dermatologist could not see her, and they put her on antibiotics, and it was not working and so she got in with the dermatologist and they put her on something stronger, so they prescribed her a second antibiotic, a steroid shot, and a topical ointment. Caller stated the ointment was a steroid ointment. Caller stated she was also on an antidepressant and birth control. Caller reporting left shoulder, arm, neck pain after receiving second dose of Pfizer COVID Vaccine. While reporting AE, caller states she had a cyst on her breast that got infected and was prescribed antibiotics. Caller states Caller stated the first prescription of antibiotics was Cephalexin. Caller unsure of LOT, NDC, Expiry date. Caller stated it was a prescription, prescribed on 31Mar2021 and says to use before 31Mar2022. Caller verified it was in a brown bottle from the pharmacy. Caller stated what happened was the cyst got infected and she went to her primary care doctor because the dermatologist could not see her, and they put her on antibiotics, and it was not working and so she got in with the dermatologist and they put her on something stronger, so they prescribed her a second antibiotic. Caller received second dose of Pfizer COVID-19 vaccination on Thursday 22Apr2021, "she was having some shoulder pain, and next day 23Apr2021 her arm, left arm where she got the shot, started hurting so bad, pain was shooting unto her neck, the pain was like nerve pain, she could not even use her arm and her husband put her on pain medication". Caller stated they had police officers there and they did have some military people outside, but they stayed in their cars. The adverse events were not resulted in visit to emergency room and physician office. The outcome of shoulder pain, her arm, left arm where she got the shot, started hurting so bad/could not even use her arm, pain was shooting into her neck was resolving and rest all other events was unknown.  No follow-up attempts are needed. No further information is expected.