Age: 74.0
Sex: M
Vaccine: COVID19
Symptoms: Gait disturbance, Head discomfort, Headache, Nasopharyngitis, Neck pain
Clinical narrative: Soreness in arm; Also "poo-pooed."; 4 weeks after the second dose felt unsteady on his feet, when he went to get up out of the chair, he took a tumble; Wax buildup in his right ear; Tinnitus; Fullness in his head; Lots of mucus when he wakes up; Cannot walk in a straight line without a cane, couldn't walk heel to toe; Feels like a bad head cold; Neck pain was improved minimally; mild headache; Chills; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of PAIN IN EXTREMITY (Soreness in arm), DIARRHOEA (Also "poo-pooed."), DYSSTASIA (4 weeks after the second dose felt unsteady on his feet, when he went to get up out of the chair, he took a tumble), EXCESSIVE CERUMEN PRODUCTION (Wax buildup in his right ear) and TINNITUS (Tinnitus) in a 74-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 032M20A and 024M20A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below.     No Medical History information was reported.   On 15-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 16-Mar-2021, received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 1 dosage form. On an unknown date, the patient experienced PAIN IN EXTREMITY (Soreness in arm), DIARRHOEA (Also "poo-pooed."), DYSSTASIA (4 weeks after the second dose felt unsteady on his feet, when he went to get up out of the chair, he took a tumble), EXCESSIVE CERUMEN PRODUCTION (Wax buildup in his right ear), TINNITUS (Tinnitus), HEAD DISCOMFORT (Fullness in his head), SECRETION DISCHARGE (Lots of mucus when he wakes up), GAIT DISTURBANCE (Cannot walk in a straight line without a cane, couldn't walk heel to toe), NASOPHARYNGITIS (Feels like a bad head cold), NECK PAIN (Neck pain was improved minimally), HEADACHE (mild headache) and CHILLS (Chills). At the time of the report, PAIN IN EXTREMITY (Soreness in arm), DIARRHOEA (Also "poo-pooed."), EXCESSIVE CERUMEN PRODUCTION (Wax buildup in his right ear), SECRETION DISCHARGE (Lots of mucus when he wakes up) and CHILLS (Chills) outcome was unknown and DYSSTASIA (4 weeks after the second dose felt unsteady on his feet, when he went to get up out of the chair, he took a tumble), TINNITUS (Tinnitus), HEAD DISCOMFORT (Fullness in his head), GAIT DISTURBANCE (Cannot walk in a straight line without a cane, couldn't walk heel to toe), NASOPHARYNGITIS (Feels like a bad head cold), NECK PAIN (Neck pain was improved minimally) and HEADACHE (mild headache) had not resolved. Not Provided    DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On an unknown date, Computerised tomogram: (normal) Normal and normal (normal) CT scan showed nothing.         Patient went to Primary Care Doctor who cleaned wax buildup in his right ear and then to ENT Doctor, Neurologist and to the Chiropractor. No concomitant medications were reported Treatment Information includes Ibuprofen, Antihistamines.   This case was linked to US-MODERNATX, INC.-MOD-2021-089483, US-MODERNATX, INC.-MOD-2021-090115, MOD21-081386, MOD21-082730 (E2B Linked Report).   Most recent FOLLOW-UP information incorporated above includes: On 27-Apr-2021: Followup information was received on 27 APR 2021.Added new events Head cold, Neck pain, Headache.Outcome of the events Dystasia, Tinnitus, Head discomfort Gait disturbance changed from Unknown to not recovered.Route of administration of vaccine was added.Treatment Information was added.; Sender's Comments:  US-MODERNATX, INC.-MOD-2021-089483: US-MODERNATX, INC.-MOD-2021-090115: MOD21-081386: MOD21-082730: