Age: 60.0
Sex: M
Vaccine: COVID19
Symptoms: Gait disturbance, Gastrointestinal disorder, Illness, Investigation, Magnetic resonance imaging heart
Clinical narrative: was the sickest he's ever  been; Couldn't hold any food down; Dizziness; Could hardly breathe; Could hardly walk; Had aches and pains everywhere; His legs were extremely painful; It hurt to breathe; Could tell his chest was heavily congested; Staph infection; This is a spontaneous report from a contactable consumer (patient himself). A 60-year-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection; Batch/Lot number was not reported) via an unspecified route of administration, administered in left arm, on 22Jul2021 (at the age of 60 years old) as dose 1, single for COVID-19 immunisation. Medical history included Type 2 Diabetes from 2018 (diagnosed 2.5 years ago) and ongoing. Patient stated that it can be controlled by diet, but since he's in skilled nursing facility and they didn't have diabetes-type friendly food, they have everything loaded with sugar, they have him on insulin, he knew for a fact if he watched what he eats that's not that big of a deal. There were no prior vaccinations (within 4 weeks) within four weeks prior to the first administration date of the vaccine. Concomitant medication included insulin taken for type 2 diabetes mellitus, start and stop date were not reported. It was reported that the patient had an adverse reaction to the first Covid 19 shot. He stated that he got a Covid 19 shot from withheld on 22Jul2021, he didn't have any reaction for the first 30 minutes, so they released him, and he went home. The next day, the patient woke up and was the sickest he's ever been (hospitalized). The patient could hardly breathe, could hardly walk, had aches and pains everywhere. The patient called the pharmacy and told him to wait a couple days and to take Tylenol for pain, so he followed their guidance, and after 2 days, there was no improvement. The patient could hardly walk, he could tell his chest was heavily congested, it hurt to breathe, his legs were extremely painful, and the worse he's ever had in his entire life. The patient stated since things weren't getting any better, he decided to call the emergency team on Tuesday and they told him he should go to the hospital, and to not even bother with urgent care, so he went to the hospital, and they verified that he had an adverse reaction to the Covid 19 shot, and that if he had waited another day he probably would have died from it, they got him out of the woods, it didn't take them very long to do that, but then he found out he has a staph infection (medically significant), and they had him on antibiotics for over 8 weeks. The patient stated he took care of the pain for his legs and got icy hot as treatment. The hospital wouldn't listen to him, so he got a friend of his to give him icy hot, and in 4 days that cleared up most of the pain in his legs, and after 2 weeks, his legs were totally back to normal. The patient reported that everything has been cleared up, all his symptoms. The patient has had x-rays, MRI's, CAT scans, and everything. The patient stated that the last thing he has left is, this just started Sunday, was dizziness. He stated but that's going away, it was really bad Sunday, and he couldn't hold any food down, but it's nowhere near as bad as it was on Sunday. The patient confirmed that the dizziness began Sunday, 12Sep2021, and ongoing but improved. The patient was still having a little bit of dizziness. The patient couldn't hold any food down and confirmed it began on 13Sep2021 and ended 14Sep2021, confirmed has recovered completely. He stated he started eating yogurt and eventually he was able to hold food down later that day. The patient also stated that his lungs are cleared up, he didn't know when his lungs cleared up, and reported sometime in Aug2021, towards the end of August. The patient confirmed that he was hospitalized from  27Jul2021 to Aug2021, unsure of exact date; he stated he was in a skilled nursing facility because they put him on IV antibiotics, and they have to do it 3 times a day, they didn't want to give him pills because they didn't think that was going to work, the person for disease control told him they highly recommended him going to a skilled nursing facility, she was pretty much yelling at him to do it. He was discharged Aug 2021 and went to that skilled nursing facility. After he had that kind of reaction to it, he's definitely not going to get a second shot or booster shot. The patient confirmed that he had x-rays, cat scans, and MRI's in Aug2021. MRI of Heart showed that it found out that was clean, they were on a fishing expedition because they couldn't find out where that infection came from, confirms in Aug2021. MRI Spine came up clear, confirmed in Aug2021. They couldn't find any puncture marks, cuts, or anything like that where it would have come into. They also shoved a probe down his throat to get a better picture and did a biopsy on his lungs to make sure it wasn't cancer, and that turned out negative on cancer, confirmed done in Aug2021. The events required a visit to Emergency Room. The outcome of the event dizziness was recovering, for the event gastrointestinal disorder was recovered on 14Sep2021, while for the remaining events was recovered on 01Aug2021.  The lot number for the vaccine, BNT162B2, was not provided and will be requested during follow up.