Age: 78.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Gait disturbance, Heart rate increased, Lethargy, Pyrexia, SARS-CoV-2 test
Clinical narrative: March 3, 2021 SUBJECT: Moderna COVID-19 Vaccine, Side Effects This letter/email is addressed to a number of individuals with a request that you seriously evaluate the below discussion, take action to alert medical staff of your respective agencies of these side effects, and work with the manufacturer, Moderna, to address them.  As the recipient of them it has thus far been debilitating and interfered with my daily activities.  It is my hope that the medical community can find ways to prevent or treat them such that daily activity can be unimpeded.     I will first provide a chronology of my medical history and my Moderna vaccine experience.  Then I will discuss my observations. My medical history: Age: 78 Gender: Male Pre-existing Conditions: Medications  Hypertension: Blood pressure medication, 50 mg of Metoprolol Succinate ER daily  Cholesterol: Atorvastatin, 40 mg daily Medical History   2018: Triple By-Pass Surgery 2019: Passed out, Hit head on falling, Brain bleed: Subdural Hematoma, Hospitalized: No surgery required and released.  Subsequently, pacemaker installed. 2021: Moderna COVID-19 Vaccine administered.  First Dose: Lot Number: 011J20A, Date: 01/08/2021, Clinic Site: Pharmacy  Second Dose: Lot Number: 032L20A, Date: 02/05/2021, Clinic Site: Pharmacy  Side Effects to Moderna Vaccine administration  First Dose: Administration Site: Swelling, Site Redness and Fever.  All dissipated within week after administration  Second Dose: Fever and Chills day following administration.  Lethargic for several days following administration.  These symptoms disappeared. Observations  February 24, 2021: Began to experience dizziness, symptoms progressed to mild vertigo.  Based on history of presentation of these symptoms, assumed I had an inter-ear problem and began taking Zyrtec D, half a tablet.  Experience with Zyrtec D has been that ear dries out and symptoms of dizziness and disorientation disappear.  In this case the symptoms of vertigo progressed to the point of difficulty in walking and loss of balance. Stopped taking Zyrtec D on Friday, February 26th.  February 26, 2021: Had more severe vomiting, walking difficulty and lose of balance.  Used walker to stabilize walking.  At approximately 7 to 7:30 PM, following consultation with wife and daughter, decided to go the emergency room of the Medical Center (MC).  Was quickly seen by emergency room staff.  Following questions on medical history, the ER doctor, based on head bleed history, I believe, had a CT conducted.  I do not recall any questions about COVID-19, but do think we told them that both myself and my wife had been vaccinated for COVID-19.  I specifically recall that prior to my transport, a nurse came in to do a nasal swab for COVID-19.  I informed her that I had been vaccinated, but she said this was a requirement for admission to the location where I was being transported.  Following the CT scan, the ER physician determined he believed there was a possibility of a small new brain bleed.  At approximately 2 to 2:30 AM I was transported by ambulance to Health Center at approximately 5:00 AM.  I am not certain about the exact times here.  February 27, 2021: Health Center administered a number of tests including CT scan, EKG, and an echocardiogram.  While there, physical therapists came to see me twice and exercised me to improve my balance and walking ability.  The last one recommended exercises to help reset my vestibular system.  Based on the administered CT scan there, the physicians saw no evidence of a new brain bleed and were prepared to release me.  At the time of that discussion in my room, the attending nurse pointed out to the physician there that my blood pressure was elevated.  He ordered a new EKG and deferred on releasing me until a cardiologist reviewed the results.  Their concern was that I was experiencing episodes of atrial fibrillation (AFib).  Subsequently, the cardiologist reviewed the new EKG and concluded the episodes were within the normal range, my understanding, but did note that my heart rate was elevated.  At no time did the medical staff raise or question the possibility of COVID-19 side effects as being a possible explanation for my disorientation or heart rate problem.  I was released later that day.  February 28, 2021:  While speaking to her sister, my wife shared with her my experience of dizziness and disorientation.  Her sister related that her husband had and was experiencing a similar event.  Further, her husband?s sister had experienced a similar event.  Additionally, the husband?s sister had experienced vertigo.  On further discussion it was determined all three of us had received the Moderna Vaccine, and approximately three to four weeks post second dose administration, developed these symptoms of vertigo.  This prompted me to go to the internet for information on vaccine side effects.  The Food and Drug Administration Fact Sheet, revised 12/2020 in the Section Titled: What are the risks of the Moderna COVID-19 vaccine? speaks of severe allergic reactions including: a fast heartbeat and dizziness and weakness.  I believe that I have suffered these two reactions.  March 1, 2021:  Called both hospitals to alert them to inform their respective staffs of the need to question the possibility of these side effects should other patients present in their emergency rooms.  In my case, it may have helped to alleviate my concerns had I been informed of these possible side effects.  At MC I left a voice mail for the Chief Medical Officer and at Health Center I spoke to the Nursing Supervisor.  The nursing supervisor advised me to report my side effects and directed me to call the entity who had administered the vaccine doses.  I called the Pharmacist and spoke to her.  She said she would report my concerns through her reporting system.  Further she informed me that there was a medication my primary care provider could prescribe.  I called my primary care provider, and he has prescribed Meclizine, 25 mg tablets.  I am currently taking ½ tablet, three times per day.  A whole tablet made me drowsy.  As of today, March 3, 2021, I am still experiencing disorientation.  Hopefully this will subside and disappear. The above discussion is provided to assist medical professionals to further assess the side effects of the Moderna COVID-19 Vaccine.  I am glad that I received it.  I have no complaint about the care I received at the two medical facilities referenced.  In fact, I think it was excellent.  However, it would have helped me to have raised by either or both of them that my symptoms may have been COVID-19 Vaccine related.  Further, it may have changed how they proceeded in assessing my situation. As an industrial hygienist with statistical training, it seems to me somewhat unusual to have three members of my extended family experiencing similar dizziness and weakness side effects, and for us all to have similar time periods following the administration of the second dose.  Perhaps, if related to the vaccine, this cluster would suggest that this side effect may be more common than a ?remote chance.?  Should any of you have further questions or wish to speak to me, please do not hesitate to call.  Since I get a lot of calls from numbers I do not recognize, I do not always answer, but a voice mail left with a return call number normally results in a return call. Today, I received a return call from the Chief Medical Director of MC and told her she would receive a copy of this document. Thank you for your attention to this matter.