Age: 72.0
Sex: M
Vaccine: COVID19
Symptoms: Nausea, Oxygen saturation, Pain in extremity, Pyrexia, SARS-CoV-2 test
Clinical narrative: tired; headache on the top of his skull /the headache is on the top of his head noting that the pain level was a 7 and now down to a 5 with or without medication; temperature started going up/his baseline temperature is 97.1 and his temperature has gone to 98.5 to 99.3; low grade temperature; Sick; a little bit of nausea; his arm was sore; This is a spontaneous report from a contactable consumer (patient). A 72-year-old male patient received bnt162b2 (Pfizer-BioNTech COVID-19 Vaccine, solution for injection, Lot Number: EW0153), via an unspecified route of administration, administered in right arm on 23Apr2021 10:30 (at the age of 72-year-old) as dose 2, single for covid-19 immunization. Medical history included bowel obstruction from 09May2020 to 09Jun2020, perforated colon and had chest wall hernia what he called an abdominal trampoline, both from an unspecified date in 2008 to an unknown date, neck surgery on 2016, knee surgery and achilles operation on 2011. He said while he was in there he got all the COVID symptoms. He says blood poisoning, high blood pressure, diabetes, 2 blood clots, he lost hearing for 6 months. When asked if he was tested for COVID he said 4 times on an unknown date, they couldn't find it (negative), but he had all the symptoms. He says he was in the ICU because he couldn't breathe. He says he went in there no problems, his oxygen was 67% and they were going to put him on a ventilator. He says he didn't have it when he went in there. He says he wasn't sick at all except the bowel obstruction. He says the bowel obstruction was because of scar tissues from way back in 2001 when he had a perforated colon. Patient previously received first dose of BNT162B2 (Pfizer-BioNTech COVID-19 Vaccine, solution for injection, lot number: ER8730, Expire Date: unknown) via an unspecified route of administration, administered in right arm on 26Mar2021 10:30 (at the age of 72-year-old) as dose 1 single for covid-19 immunisation and had no side effects. Patient previously also received Flu shot from an unspecified date in 2020 (Sep2020 or Oct2020). Concomitant medications included ongoing acetylsalicylic acid (ASPIRIN (E.C.)), he has been taking this medication for 30 years for an unspecified indication; he has been taking 30 different herbals and some vitamins every day since 30 years. It was stated that the patient reported that his arm was sore on the first day on 23Apr2021. The patient stated that he has been sick, he was tired and got a headache on the top of his skull on the second day, little bit of nausea, a little bit of nausea, had a low grade temperature on 24Apr2021. The patient reported that he started taking his temperature and stated his temperature started going up on 24Apr2021, noting it mostly goes up in the afternoon. Caller stated his baseline temperature was 97.1 and his temperature has gone to 98.5 to 99.3. The patient stated the headache was on the top of his head noting that the pain level was a 7 and now down to a 5 with or without medication. Caller stated he took acetaminophen, Aspirin and ibuprofen every four hours. Patient stated he does not have a problem in the moorings stating it starts in the afternoon. Caller wanted to know how long these side effects last. Caller noted that he is on day 10. Caller wanted guidance on what to do. When referred to his primary care physician for medical advice, he said she already talked to him and the doctor couldn't give him any information. He said calling his doctor didn't do him any good so now he was calling us. He says that we know what goes on, we have a good understanding, and his doctor doesn't know. He says he was looking for something to put his mind at ease at lease. Clinical course as follows: He says he has had a low grade temperature for 10 days. He says he fairs better when taking Aspirin 2 or 3 times a day. He said that the headache was better now. He says he thinks the dose was 325mg and he takes two at once. He says he also takes one dose of acetaminophen 500mg once or twice a day when he remembers. He says he maybe takes an antacid once and a while because the nausea was mild. He thought the antacid was Tums, he does not know the dose but says he takes 2 or 3 a day only if he needs it, as needed. He says half a dose depending on the time of day. He says his temperature was lower in the morning and as the day gets up it starts to grow. The patient did not visit to emergency Room and physician Office. No additional vaccines administered on same date of the Pfizer suspect. No Prior Vaccinations within 4 weeks (List any other vaccinations within four weeks prior to the first administration date of the suspect vaccine). Therapeutic measures were taken as result of all events. The outcome for the events of Headache was recovering, low grade temperature; events of Body temperature increased, Nausea was not recovered and all other events was unknown.  No follow-up attempts are needed. No further information is expected.