Age: 27.0
Sex: M
Vaccine: COVID19
Symptoms: Fatigue, Myalgia, Nausea, Rash
Clinical narrative: Nausea; fatigue; a rash like redness appeared on the arm of injection from the wrist to elbow; muscle pain; This is a spontaneous report from a contactable consumer or other non-healthcare professional. A 42-year-old male patient received bnt162b2 (COMIRNATY, Formulation: Solution for injection, Batch/Lot Number: FF4206), first dose via intramuscular, administered in upper left arm on 23Aug2021 at 14:30 (at the age of 42-year-old) as dose 1, 0.3 ml single for COVID-19 immunisation. Medical history included hospitalization from an unknown date and unknown if ongoing, exposure to sars-cov-2 from an unknown date and unknown if ongoing. Concomitant medications included vitamin c [ascorbic acid] (VITAMIN C [ASCORBIC ACID]) taken via oral for an unspecified indication from an unspecified start date and ongoing; vitamin d [vitamin d nos] (VITAMIN D [VITAMIN D NOS]) taken via oral for an unspecified indication from an unspecified start date and ongoing; ascorbic acid, biotin, calcium pantothenate, calcium phosphate, chromic chloride, colecalciferol, copper sulfate pentahydrate, cyanocobalamin, dl-selenomethionine, ferrous fumarate, folic acid, inositol, magnesium phosphate, manganese sulfate, nicotinamide, potassium iodide, potassium sulfate, pyridoxine hydrochloride, retinol acetate, riboflavin, sodium borate decahydrate, thiamine mononitrate, tocopheryl acid succinate, zinc sulfate (MULTI VITAMIN & MINERAL) taken via oral for an unspecified indication from an unspecified start date and ongoing. The patient previously took clopidogrel (CLOPIDOGREL), OBH syrup (OBH), warfarin (WARFARIN), levofloxacin (LEVOFLOXACIN), vitamin zinc (ZINC), and vitamin e [vitamin e nos] (VITAMIN E [VITAMIN E NOS]). The patient previously took clopidogrel, OBH, warfarin, levofloxacin. However, the patient informed that 2 (two) months ago the patient hospitalized because got infected with COVID-19. During hospitalization, the patient received anti-clotting drug clopidogrel for 5 (five) days, OBH syrup, warfarin with frequency of use twice a day for 7 (seven) days, antibiotics levofloxacin with frequency of use twice a day, vitamin c [ascorbic acid], vitamin d [vitamin d nos], vitamin zinc, and vitamin e [vitamin e nos]. The patient still regularly consumed vitamin c [ascorbic acid], vitamin d [vitamin d nos], and ascorbic acid, biotin, calcium pantothenate, calcium phosphate, chromic chloride, colecalciferol, copper sulfate pentahydrate, cyanocobalamin, dl-selenomethionine, ferrous fumarate, folic acid, inositol, magnesium phosphate, manganese sulfate, nicotinamide, potassium iodide, potassium sulfate, pyridoxine hydrochloride, retinol acetate, riboflavin, sodium borate decahydrate, thiamine mononitrate, tocopheryl acid succinate, zinc sulfate, via oral until now to maintain body resistance. However, the patient took the two vitamins as he could remember, usually once a week or every 4 (four) days. The physician had informed the patient that after got injection with bnt162b2 vaccine, the patient might felt pain and fever for 1-2 days. The patient also received 2 (two) tablets of paracetamol (PARACETAMOL) for anticipation in case the patient felt pain or fever. On 23Aug2021 at 22:00, the patient informed that he experienced stiff and pain in the injection site like the muscles were beaten. Those events still being felt until the time of reporting (24Aug2021). The patient did not take any medication to treat the side effects that occurred. The patient confirmed that all the side effects he experienced were not serious and did not cause him to visit the Emergency Room, Physician Office, or Intensive Care Unit (ICU) and no surgery was performed. The patient was also not hospitalized. The patient had no relevant drug history, history of drug or alcohol abuse, drug allergies, and family history of illness. The patient also did not undergo relevant tests to the side effects that occurred. The patient did not receive another vaccine within 4 (four) weeks before got injected against bnt162b2. The patient was healthy before vaccinated with bnt162b2. It was reported that the patient informed that he experienced sore which felt stiffness (previously it was informed as stiff in the injection site, and it was confirmed as a sore which felt stiffness) and pain in the injection site like the muscles were beaten on 23Aug2021 at 22.00. The patient had recovered from those events, but he forgot when the exact date. In about a week after vaccination, on 30Aug2021, the patient experienced pain in chest like being stabbed. Then the patient visit Physician Office and the physician diagnosed patient experienced gastroesophageal reflux disease (GERD). The patient was given an anti-GERD drug (magnesium hydroxide, aluminum hydroxide (ANTASIDA)) by the physician, and currently, the patient had recovered and did not have other complaints. But the patient forgot when the exact date he recovered from GERD. At the time when vaccinated with bnt162b2 on 23Aug2021, the patient was measured for his blood pressure with normal result which was 110/70. But when the patient went to the physician on 30Aug2021, his blood pressure became 130/80. The patient was ever positive of COVID about 2 (two) months ago, and at that time his cholesterol was increased, and his blood pressure also increased became 140. Hence the patient also received prescription of cholesterol drug by that physician. According to the patient, there was also a possibility that the event experienced by the patient a week after vaccination was also caused by bnt162b2. All events outcomes were reported as recovered on an unspecified date.  According to the patient, there is a possible causal relationship between bnt162b2, and the side effects experienced by him. The patient said that the stiff and pain in the injection site were most likely caused by bnt162b2.  No follow-up attempts are needed. No further information is expected.