Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, Axillary pain, Feeling abnormal, Muscle injury, Myocardial infarction
Clinical narrative: Her arm feels swollen at times and that it hurts so bad it feels strangled; soreness and pain all on the left side, muscle problems, joint pain in the elbow, wrist, 2-3 fingers usually the outside fingers hurt, painful ache in left shoulder, and sever arm pain.; Muscle problems; painful ache left shoulder; Underneath left armpit , zings when pressed in; started experiencing some difficulty; having a heart attack and was hurting everywhere especially the left arm; This is a spontaneous report from a contactable consumer or other non-health care professional. A 68-year-old female patient received dose of bnt162b2 (BNT162B2, solution for injection, Batch/Lot Number: EN6201) via an unspecified route of administration and administered in left arm on 13Feb2021 08:00 (age at vaccination was 68 years) as dose 1, single for COVID-19 immunization. The patient didnt had any vaccinations prior four weeks. No additional vaccines administered on same date of covid vaccine administration. The patient medical history include High Blood Pressure around the late 1990s, 2000s, diabetes mellitus from 2015. Patients concomitant drugs include hydrochlorothiazide taken for high Blood Pressure 25 mg once a day, losartan taken for High Blood Pressure 100mg orally once a day, metformin taken for blood glucose abnormal from 2016 1000mg twice daily. Patient first shot on 13Feb2021 around 8 PM that night, Saturday 14Feb2021 started experiencing some difficulty, by Sunday 15Feb2021 caller reports soreness and pain all on the left side, muscle problems, joint pain in the elbow, wrist, 2-3 fingers usually the outside fingers hurt, painful ache in left shoulder, and sever arm pain. She reports that she has been to the doctor and no one knows if it is from the Covid shot or not, she has had different test taken and no one can pinpoint what is going on. she thought she was having a heart attack and was hurting everywhere especially the left arm. She stated the pain ballooned and that is when she went to the doctor. having pain that runs from left shoulder down arm and around underneath the arm pit that zings when you put pressure on it, it causes pain. She said it hurt where her lymph nodes are. And she said the pain goes down to the fingertips. Patient said as far as the shoulder pain she is unsure if it is muscle pain or joint pain. But it is painful, and it aches. a scale of 1-10 she told the doctor it was a 10. Patient said she dont have fever. Her arm feels swollen at times and that it hurts so bad it feels strangled. Its like stopping dead in the water; she has not been good for the last 2 weeks and severe pain going down her arm. she has High Blood pressure and diabetes. she states this is part of the reason she got the vaccine as she is in the high-risk category. Events doesnt leads to hospitalization but require physician visit and emergency room. Therapeutic measures were taken as a result of events with steroid was Methylpred 4mg dose pack started 24Feb2021 and completed 01Mar2021. This was prescribed because doctor thought the steroids would help get everything under control of the pain. She also clarified that the muscle relaxer was Cyclobenzaprine which she spelled cylobenzap. She states the dose was 10mg orally and was prescribed to help the other medication work with to knock some of the soreness out. Medication was started 23Feb2021 and completed 01Mar2021. She does not have a lot or expiration for the Methylpred or the Cyclobenzaprine, states it was not on either bottle. She mentioned that these medications did not do very good. Declines to provide HCP information at this time but states she has been to see the doctor 16Feb2021. Lisinopril was changed to losartan because they had to try and get the right blood pressure medication for her and was changed in the late 1990s. She was on Lisinopril for 2-3 years. She has no lot number, expiration, or NDC to provide. Her appointment time was 7 pm but she received the vaccine somewhere between 7:30 an 8pm. she wanted to start life over again and do the things she did before. The patient underwent lab tests and procedures which included pain assessment: 10 on Caller says on a scale of 1-10 she told the doctor it was a 10, x-ray: unknown result on unknown date (she seen the doctor and got x-rays and all kinds of stuff). Second Covid vaccine is scheduled for this Friday. She stated she does not know what else to do, she is supposed to see the doctor this afternoon and is trying to gather information from Pfizer that can help them in any way. Caller reporting on COVID Vaccine. Caller mentioned she was taking Methylpred and Cyclobenzaprine and they did not help. Caller clarified the steroid was Methylpred 4mg dose pack started 24Feb2021 and completed 01Mar2021. This was prescribed because doctor thought the steroids would help get everything under control of the pain. She also clarified that the muscle relaxer was Cyclobenzaprine which she spelled cylobenzap. She states the dose was 10mg orally and was prescribed to help the other medication work with to knock some of the soreness out. Medication was started 23Feb2021 and completed 01Mar2021. She does not have a lot or expiration for the Methylpred or the Cyclobenzaprine, states it was not on either bottle. She mentioned that these medications did not do very good. Caller also mentioned detail about a historical medication which was Lisinopril. Lisinopril was changed to Losartan because they had to try and get the right blood pressure medication for her and was changed in the late 1990s. She was on Lisinopril for 2-3 years. She has no lot number, expiration, or NDC to provide for the Lisinopril. The outcome of events Muscle problems, Joint problems in elbow, wrist, and 2 outside fingers/soreness and pain all on the left side, muscle problems, joint pain in the elbow, wrist, 2-3 fingers usually the outside fingers hurt, painful ache in left shoulder, and sever arm pain, painful ache left shoulder, Underneath left armpit , zings when pressed in was not recovered and outcome of events started experiencing some difficulty, Her arm feels swollen at times and that it hurts so bad it feels strangled and having a heart attack and was hurting everywhere especially the left arm was unknown.  No follow-up attempts are possible. No further information is expected.