Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Haptoglobin, Haptoglobin increased, Imaging procedure, Investigation, Loss of consciousness
Clinical narrative: found down unconscious; unwitnessed fall; oxygen was in the 60s; submassive bilateral pulmonary emboli; right femoral vein emboli/ occlusive thrombus visualized in the right proximal femoral vein; some degree of right heart dysfunction; blood sugar very high; A1C elevated; Haptoglobin elevated; elevated troponin; This is a spontaneous report from a contactable nurse. A 67-year-old male patient received second dose BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Solution for injection; Lot number was not reported) via an unspecified route of administration, at the age of 67-year-old, on 25Feb2021, as SINGLE DOSE for covid-19 immunisation.  Medical history included Traumatic brain injury at the age of 29 which resulted in a CVA (right sided stroke)because the hospital did not know how to give Mannitol, behavioral problems in 2008, run over by a train in 2008, wears two AFOs (one on the left leg from having a right sided stroke, he also wears one on his left leg from having a stroke with right sided weakness, the right AFO was worn since he was 29, and then the other one he started wearing in 2008 when he was run over by a train and almost had his leg severed and he wears a left AFO), dementia diagnosed 4-5 years ago, head surgeries, depression, affective disorder, anxiety. The patient had multiple hospitalizations, and he has hyper reflexivity like all brain patients have. The patient has no history of blood clots or emboli. Concomitant medications included olanzapine (ZYPREXA) taken for depression and oxcarbazepine (TRILEPTAL) taken for affective disorder and anxiety.  The patient received first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Solution for injection; lot number not reported) single dose for covid-19 immunisation, pneumonia and flu vaccine in 2008 for immunization and has no reaction. The patient received his second dose of the vaccine on 25Feb2021 and two weeks later he was found down/ was found down unconscious at the nursing home and his oxygen was in the 60's on 15Mar2021. The nursing home did not know if her brother hit his head because it was unwitnessed. The patient was found down, not responsive, and it was an unwitnessed fall. The patient was treated as a trauma patient and that this occurred around 10 oclock on 15Mar2021. At that time, he was transferred to a local hospital to the emergency room and put on oxygen. They transferred him within 4 hours because they did not know what to do. Caller adds that the hospital thought that he had a subdural hematoma but the hospital does not have a neuro radiologist, so the hospital transferred to the other hospital that somebody with head knowledge can look at his CAT scan. The patient was misdiagnosed with a subdural hematoma because there were changes in his CT scan from his 3 previous brain surgeries. The patient had a traumatic brain injury when he was 29, and experienced changes.  The patient was found to have submassive bilateral pulmonary emboli on 15Mar2021 described as central lobar sub segmental PEs in both lungs, PE was within the distal right main artery, pulmonary artery distal left main, left middle lobe, middle right lobe / upper right lower lobe and middle lobar, segmental and sub segmental pulmonary arteries. The patient also had pulmonary emboli in the distal left main pulmonary artery of left middle lobe and left lower lobe, pulmonary arteries. There was also some degree of right heart dysfunction which was diagnosed by contrast. On 15Mar2021, the patient also had right femoral vein emboli/ occlusive thrombus visualized in the right proximal femoral vein. The patient is in a nursing home, the doctor did not want to listen to the reporter because her brother is a nursing home patient and they just assume he is immobile but he is not.  The patient underwent lab test and procedures which included Blood sugar very high (they think it was because of heart strain and acute injury because then it came down down down), A1C elevated, Haptoglobin elevated, elevated troponin. These results were all elevated and from acute injury. At the time of the report, the patient is feeling better and needs less oxygen. The events found down unconscious, unwitnessed fall and oxygen saturation low, pulmonary embolism, right femoral vein emboli/ occlusive thrombus visualized in the right proximal femoral vein, and some degree of right heart dysfunction caused hospitalization from 15Mar2021 to 18Mar2021. The reporter absolutely does believe the events and the suspect drug are correlated. Outcome of found down unconscious, unwitnessed fall and oxygen saturation low, pulmonary embolism was recovered on 18Mar2021 while it was unknown for the other events.