Age: 62.0
Sex: M
Vaccine: COVID19
Symptoms: Activated partial thromboplastin time, Angiogram, Coronary artery disease, Echocardiogram, Full blood count
Clinical narrative: Coronary artery disease; mild tenderness of the injection site of right deltoid; This is a spontaneous report from a Pfizer sponsored program from a contactable consumer (patient). A 62-year-old male patient received bnt162b2 (reported as Pfizer Covid-19 Vaccine), dose 1 intramuscular, administered in deltoid right on 18May2021 14:00 (Batch/Lot Number: EW0172) as 1st dose, single at the age of 62-year-old for covid-19 immunisation. Medical history included essential thrombocythaemia from May2014 and ongoing (Outpatient at withheld since 2015 for this condition. This is a myeloproliferative disorder where bone marrow makes too many blood platelets. Previously on chemotherapeutic agent hydroxyurea from time of diagnosis May2014 until 29Jun2020. Has not been on any other medication since then except low dose aspirin), chest pain, headache, and nausea from 2021 (all started approximately 4-6 weeks prior to 20May2021). The patient's concomitant medications were not reported. The patient previously took acetylsalicylic acid (ASPIRIN) (reported as Low Dose Aspirin) at 81 mg from May2014 and ongoing for essential thrombocythaemia, hydroxycarbamide (HYDROXYUREA) for essential thrombocythaemia from May2014 to 29Jun2020 (Previously on chemotherapeutic agent hydroxyurea from time of diagnosis May2014 until 29Jun2020). Patient received the first dose of bnt162b2 18May2021. From 20May2021 to 25May2021 he got hospitalized and took a blood thinner for 5 days. He is scheduled to receive the second dose of bnt162b2 on 08Jun2021. He wants to know if he can still get the second dose of bnt162b2 if he took the blood thinner for 5 days when he got hospitalized. Patient clarified that he was administered his first dose of bnt162b2 on 18May2021. He reported having chest pains, headaches and nausea that all started approximately 4-6 weeks prior to 20May2021 which was the date he was admitted to the hospital relative to those events. He specified that these events were ongoing prior to him ever being administered the bnt162b2. He was admitted to the hospital on 20May2021 until discharged on 25May2021. He has had no further episodes of these events, but whether recovered completely or with lasting effects is unknown. Patient is a retired medical laboratory technician, has a degree, has worked in medical labs in the past but is currently retired. Admitted to hospital as cardiac patient with no cardiac history prior to initial onset of these events around 4-6 weeks prior to 20May2021. He was brought to the hospital emergency department via ambulance that he himself called. While hospitalized they recommended surgery to him, he declined surgery, left the hospital and is seeking another opinion. While hospitalized he was administered blood thinner or anti-coagulant Heparin intravenously. He was not sure if he started Heparin on 20May2021 or 21May2021, but thinks it was from 21May2021 to 25May2021. He thinks he was brought to the hospital and admitted somewhere between 22:30 on 20May2021 and 00:00 21May2021; but verified hospitalization repeatedly as starting 20May2021. Patient provided additional details regarding these events: about 4-6 weeks prior to 20May2021 he had been having rather severe headaches, nausea and chest pain-not constantly, but having them. He had been able to function, in other words take care of himself, do business although sometimes a bit difficult and uncomfortable because of those symptoms but got it done. On 20May2021 when this continued he had been pretty busy that day out from about 10:00 or 11:00 until about 21:30. He accomplished everything he wanted to do that day, had eaten a couple of times. He had no headaches that day, had some chest pains, nausea but at end of day when he came home about 21:30 he had the worst chest pain of the day. Because he had been having these types of symptoms: headaches, nausea, chest pain for 4-6 weeks before that, he called ambulance went to local hospital called his primary doctors' office before he did that; and so they agreed he should go so he did. The tests that were performed were amongst many blood tests from CBCs to chemistry to PTT to a PTT because he had been put on heparin particularly. Maybe a lipid profile type test, was given an echocardiogram and an angiogram. Put on a cardiac unit; no prior cardiac history or heart problems prior to this. Regarding results they were saying he had coronary artery disease; that had 3 modes of treatment: anything from medication regimen only to stent to bypass or open heart surgery so that's the sort of testing that was done. He never looked, he's going to get records in the future. He has been a medical lab technologist he knows how to draw the labs; he knows what the purple top for CBC with or without diff is; he knows EDTA ethylenediaminetetraacetic acid is, he knows the light blue top is gonna be sodium citrate for coagulation studies for prothrombin time etc.; he knows the red topper is maybe chemistry; so know those kinds of things, he knows how to perform venipuncture blood sample, finger stick and heel sticks. He had no history of cardiac problems other than what appears to be going on now; never been on anticoagulant before this hospitalization. He does not believe the chest pain, nausea and headaches are attributable to the vaccine; he is not going to say it couldn't be that; but on the surface he does not think the vaccine had anything to do with the events-events were going on before he got the bnt162b2. At the time he got the bnt162b2 he believes he mentioned having essential thrombocytosis and may have mentioned that he was an outpatient at that facility. He also mentioned he had mild tenderness of the injection site of right deltoid; but that is common and expected with any intramuscular injection; he did not notice any other types of side effects he could attribute to the vaccine. The mild tenderness of the injection site of right deltoid onset date and time was immediately or shortly after the time of injection on 18May2021 and only lasted about a day, stopped about 19May2021; event was nothing unusual. Unknown if recovered completely. Product name repeatedly verified by patient. Patient provided additional details from CDC vaccine record card: Vaccine first dose Covid-19 product name/manufacturer lot number: the following information was handwritten into the card by the people who administered the vaccine to him: Pfizer EW0172. Covid-19 vaccination record card. date administered: 18May2021. Facility: withheld-which he later referred to interchangeably as withheld. When he received initial dose on 18May2021, outside of the CDC vaccine record card, he was given future appointment card and a multi-page document all together titled Fact Sheet for Recipients and Caregivers; and in that information, that's how he came to call Pfizer. There's a telephone number inside, on page 5 of this document; in the section titled additional information it says if you have questions visit the website or call telephone number provided below: withheld that's how he got the number to call Pfizer. On page 2 of that same document section: What you should mention to your vaccination provider before you get the Pfizer-BioNTech Covid-19 Vaccine? Tell the vaccination provider about all of your medical conditions, including if you have any allergies, have a fever, have a bleeding disorder or are on a blood thinner, are immunocompromised or are on a medicine that affects your immune system, are pregnant or plan to become pregnant, are breastfeeding, have received another COVID-19 vaccine. What prompted him to call was on and before 18May2021 he had not been hospitalized; he was not having any bleeding disorder or on any blood thinner. He gets the first dose on 18May2021 he is scheduled for second dose on 08Jun2021 about 21 days after the dose at same place; what prompted the call today is, he was hospitalized with chest pains. During that hospital stay was on Heparin. He was not diagnosed with any bleeding disorder. He has no longer been on any blood thinner of any kind since 25May2021. So his question is given the fact that he is scheduled for the second dose, should he still get the second dose of bnt162b2 or not. He does not want to wait until he goes back to the healthcare facility to ask them that question. As far as he knows it now, he is not seeing any other reason he could not get the second dose of bnt162b2 as scheduled. Of course that is considering that nothing else happens in the interim but he does not foresee anything happening. He does not know what time it takes for Heparin to get out of your system, hasn't researched that yet. Heparin: Lots/NDCs/Expiries: Not provided, administered in hospital. Chest pains, nausea, headaches require a visit to emergency room, the patient was hospitalized, from 20May2021 to 25May2021. Patient called in and stated that he received the fact sheet after receiving the 1st dose last 18May2021 and he noticed that there's a certain part in the fact sheet that what you will tell your vaccination center. He mentioned that he is not in a blood thinner when he received the 1st dose and after that he got hospitalized for 5 days from 20May2021 up to 25May2021 and during those days he was in a blood thinner. Now he wants to know since he will be receiving the 2nd dose on 08Jun2021, is he eligible to get the vaccine since from 25May2021 until now he is not in a blood thinner. Patient stated he received the first dose of the bnt162b2 on 18May2021 and he is scheduled to receive his second dose on 08Jun2021. Two days after his first dose, on 20May2021 he was hospitalized, he stated that he was experiencing symptoms even before receiving the vaccine, like headache, nausea and chest pain. He went to the ER on 20May2021 to get evaluated and treated and he stayed in the hospital for 5 days, from 20May2021 to 25May2021. During his hospitalization he was administered IV heparin, he hasn't received any since the got out of the hospital on 25May2021. He is not taking blood thinners currently and he does not have a bleeding disorder, but he read on the Fact Sheet for Recipients and Caregivers to mention the vaccination provider all your medical conditions including if you have a bleeding disorder or are on a blood thinner. Should he receive the second dose of the vaccine as scheduled? Patient stated he is 100% sure his hospitalization is not related to the vaccine since he had the symptoms before. He also stated that he did not experience any side effects after receiving the vaccine and that the hospital staff is aware that he received the first dose of bnt162b2 on 18May2021. The patient was recovered from mild tenderness of the injection site of right deltoid on 19May2021. The outcome of other event was unknown.