Age: 71.0
Sex: M
Vaccine: COVID19
Symptoms: Anxiety, Dysphagia, Dyspnoea, Gait disturbance, Magnetic resonance imaging
Clinical narrative: Anxiety; Muscles are weak; Was having fluid building in the esophagus; Difficulty swallowing and almost feels like when he is breathing; Pain; Vomiting; Walking real slow, Has to slow down to move down the stairs, Coordination is completely off and is one of the problems, Walking at an angle and not walking straight up, Gait instability; Shortness of breath; This spontaneous case was reported by a patient and describes the occurrence of GAIT DISTURBANCE (Walking real slow, Has to slow down to move down the stairs, Coordination is completely off and is one of the problems, Walking at an angle and not walking straight up, Gait instability), DYSPNOEA (Shortness of breath), ANXIETY (Anxiety), MUSCULAR WEAKNESS (Muscles are weak) and OESOPHAGEAL DISCOMFORT (Was having fluid building in the esophagus) in a 73-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 006C21A and 026A21A) for COVID-19 prophylaxis. The occurrence of additional non-serious events is detailed below.     Concurrent medical conditions included Anxiety, Pain, Blood pressure high and Skin discoloration (dark spots on the face). Concomitant products included CLONAZEPAM for Anxiety, VALSARTAN for Blood pressure high, TRAMADOL for Pain, HYDROCORTISONE for an unknown indication.   On 02-Apr-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 02-May-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. In 2021, the patient experienced DYSPNOEA (Shortness of breath). On an unknown date, the patient experienced GAIT DISTURBANCE (Walking real slow, Has to slow down to move down the stairs, Coordination is completely off and is one of the problems, Walking at an angle and not walking straight up, Gait instability), ANXIETY (Anxiety), MUSCULAR WEAKNESS (Muscles are weak), OESOPHAGEAL DISCOMFORT (Was having fluid building in the esophagus), DYSPHAGIA (Difficulty swallowing and almost feels like when he is breathing), PAIN (Pain) and VOMITING (Vomiting). The patient was treated with ATORVASTATIN at an unspecified dose and frequency. At the time of the report, GAIT DISTURBANCE (Walking real slow, Has to slow down to move down the stairs, Coordination is completely off and is one of the problems, Walking at an angle and not walking straight up, Gait instability), ANXIETY (Anxiety), MUSCULAR WEAKNESS (Muscles are weak), OESOPHAGEAL DISCOMFORT (Was having fluid building in the esophagus), DYSPHAGIA (Difficulty swallowing and almost feels like when he is breathing), PAIN (Pain) and VOMITING (Vomiting) outcome was unknown and DYSPNOEA (Shortness of breath) had not resolved.      DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Magnetic resonance imaging: normal Normal complete cardia review.         The patient stated that after receiving the 2 Moderna shots and had been in doctors care since and had a brain scan.  Patient  vomited once because was taking over the counter medicine for shortness of breath and was having fluid building in the esophagus so took over the counter medicine.  The patient stated that he went to the ER for MRI which was normal per patient.  The patient also reported dark spots on the face that this was even before patient had 1st dose.  Cardiac related signs and symptoms reported Shortness of breath started month after the 2nd dose  It was reported that Cardiac Lab values (ECG, cardiac test, cardiac enzymes) Had a complete cardia review (MRI) and said everything is normal in the heart.  It was reported that there were no history of Myocarditis/pericarditis and COVID-19 infection.  Further treatment medication reported over the counter medicine for shortness of breath.