Age: 65.0
Sex: M
Vaccine: COVID19
Symptoms: Gait disturbance, Gait inability, Illness, Investigation, Limb discomfort
Clinical narrative: We became sick; can't even walk; Weakness in his legs and arms; Short of breath; He has lost approximately 14 Pounds since all this started; brain is aging fast; He is forgetting; Memory loss; Unstable gait/His gait is off; Legs are wobbling; Joint pain; This is a spontaneous report received from a contactable reporter(s) (Nurse).  A 65-year-old male patient received BNT162b2, BNT162b2 omi ba.4-5 (BNT162B2, BNT162B2 OMI BA.4-5), as dose number unknown (booster), single (Batch/Lot number: unknown) at the age of 65 years for covid-19 immunisation. The patient's relevant medical history included: "Diabetes type 2" (unspecified if ongoing); "He has severe hypertension" (unspecified if ongoing); "asthma" (unspecified if ongoing); "he has chronic also renal failure" (unspecified if ongoing); "claustrophobia" (unspecified if ongoing). Concomitant medication(s) included: LOSARTAN; FARXIGA; BABY ASPIRIN; TERAZOSIN; CARVEDILOL; LEVEMIR; PHENYTOIN; METFORMIN. Vaccination history included: Covid-19 vaccine (Primary Immunization series complete; unknown manufacturer), for Covid-19 immunization. The following information was reported: ILLNESS (non-serious), outcome "unknown", described as "We became sick"; GAIT INABILITY (non-serious), outcome "unknown", described as "can't even walk"; MUSCULAR WEAKNESS (non-serious), outcome "not recovered", described as "Weakness in his legs and arms"; DYSPNOEA (non-serious), outcome "not recovered", described as "Short of breath"; WEIGHT DECREASED (non-serious), outcome "unknown", described as "He has lost approximately 14 Pounds since all this started"; CEREBRAL DISORDER (non-serious), outcome "unknown", described as "brain is aging fast"; MEMORY IMPAIRMENT (non-serious), outcome "not recovered", described as "He is forgetting"; AMNESIA (non-serious), outcome "unknown", described as "Memory loss"; GAIT DISTURBANCE (non-serious), outcome "unknown", described as "Unstable gait/His gait is off"; LIMB DISCOMFORT (non-serious), outcome "unknown", described as "Legs are wobbling"; ARTHRALGIA (non-serious), outcome "not recovered", described as "Joint pain". Relevant laboratory tests and procedures are available in the appropriate section.  Additional information: The patient received the bivalent vaccine on 24Oct and became sick that day. He can't even walk. He was not walking. He was having joint pain, weakness in his legs and arms, same similar symptoms, short of breath. The patient weight was 213 Pounds. He has lost approximately 14 Pounds since all this started. The patient is on multiple medications. He is on a long-acting insulin Levemir. He takes twice a day 35 units. He has severe hypertension. Apart from all this, he is on multiple medications, Losartan 100/25 mcg. Patient had all the profile chemistry. They said his brain is aging fast, he is forgetting. His gait is off. His legs were wobbling, it's a lot. He is on Metformin and phenytoin, they stopped it. The patient is going to go to physical therapy and that is scheduled for next week. After that they are going to see how well he does they are going to re-evaluate and do a repeat open MRI. He has claustrophobia and so they have to do an open one. He is going to outpatient because he can barely remember and know how to get to the doctor's office, memory loss, unstable gait, weakness.  The information on the batch/lot number for BNT162b2, BNT162b2 omi ba.4-5 has been requested and will be submitted if and when received.