Age: 59.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Computerised tomogram, Headache, Hypoaesthesia, Magnetic resonance imaging, Neck pain
Clinical narrative: Sore neck; Tingling around my mouth, the right side of my mouth; Tingling around the right side of my face; Numbness; my right arm is sore; My whole right side is sore; Headache; This is a spontaneous report from a contactable consumer (patient). A 59-years-old male patient received first dose of BNT162b2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection, Lot Number: EW0177), via an unspecified route on 29May2021 (at the age of 59-years) as dose 1, single in the right arm for covid-19 immunization.The patient medical history included fibromyalgia, blood pressure, cholesterol. The patient concomitant medications included atorvastatin calcium (ATORVASTATIN [ATORVASTATIN CALCIUM]) 40 mg for Cholesterol, one tablet every day at bed time, lisinopril (LISINOPRIL) 10 mg, one tablet every day for blood pressure and acetylsalicylic acid (ASPIRIN) for unspecified indication from an unknown date and unknown if ongoing. When needed. I occasionally take low dose Aspirin but that's it.The patient did not receive any other vaccines within four weeks prior to the vaccination. On 13Jun2021, the patient experienced tingling around the right side of his face, numbness, right arm was sore, whole right side was sore, headache, on 30Jun2021 the patient had sore neck, tingling around my mouth, the right side of my mouth. Patient stated that he had both COVID shots and his primary physician feels that he might have had side effects due to that COVID shot. He had been taking some Aspirin, since he had the side effects he had been taking another medicines. He stated the diagnosis date of Fibromyalgia had been since many years ago. Patient took Gabapentin 100 mg (Intent: treatment) for tingling in the right side of my face just got a week ago. Consumer stated he had the side effect with the COVID shot. The patient had both COVID shots and my primary physician feels that I might have had side effects due to that COVID shot. When probed for the side effects, consumer stated, Tingling around the right side of my face, numbness, my right arm is sore and my whole right side is sore and also a headache and sore neck, tingling around my mouth, the right side of my mouth. Consumer stated, There was no expiration# date but I took the first one 29May2021 and the second one 24Jun2021. Consumer stated, Well I have been taking some Aspirin but that's it but also I have been (incomplete sentence), since I have the side effects I have been taking another medicines, would you like them? When again probed for the diagnosis date of Fibromyalgia, consumer stated, "Oh! It's been many years ago. Consumer stated, "The first one is Atorvastatin 40 mg for Cholesterol, one tablet every day at bed time. The next one Lisinopril 10 mg, one tablet every day for blood pressure.(Further clarification was unknown, hence not captured in tab). When probed if consumer had Cholesterol and blood pressure as well, consumer stated, "That was given to me after the first side effect, after the side effect on 14th (Further clarification was unknown if consumer was experiencing Cholesterol and blood pressure after the vaccination, hence not in captured in tab) and then I am taking one as well called Gabapentin 100 mg (Intent: treatment) and that was given to me a week ago.Indication of Gabapentin: Consumer stated, For my tingling in the right side of my face.When probed if consumer started taking these medications (Atorvastatin, Lisinopril, Gabapentin) after the vaccine, consumer stated, The first two were (incomplete sentence) yeah (Further clarification was unknown). Gabapentin I just got a weak ago.The patient underwent lab tests and procedures which included computerised tomogram: negative on 27Jun2021, magnetic resonance imaging: negative on 23Jun2021, x-ray: unknown on 27Jun2021.Therapeutic measures were taken as a result of tingling around the right side of my face (paraesthesia). The patient received Gabapentin 100 mg (Intent: treatment) and that was given tothe patient a week ago.The outcome of the events was unknown.