Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: Fatigue, Gait disturbance, Headache, Movement disorder, Neurological symptom
Clinical narrative: My legs were going higher than normal and kind of falling back down and this is very weird state; it seem to be a neurological symptom; I came down and laid on the couch and I literally couldn't get off the couch/ Immobilized; nerve seemingly neurological thing; my mouth was full of like little sores; mouth sores; I lost about 5 pounds; gold tooth and it just started hurting crazy; Exhausted/ Tired; I had a rash in my entire torso, sides and back; total upper body half rash not on my arm, torso sides and back; Headache; Fever; This is a spontaneous report from a contactable consumer (Patient himself). Follow-up (17Feb2021) was received from same reporter and processed together with initial information.   A 70-year-old male patient received second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, solution for injection, lot number: EM9809) via unspecified route of administration on 13Feb2021 02:30 (at the age of 70-years) as 2ND DOSE, SINGLE in arm left for COVID-19 immunization. The patient's medical history included diabetes, heart condition, blood cholesterol, stomach discomfort. The patient's concomitant medications included Metformin for diabetes mellitus, Rosuvastatin for blood cholesterol, Chlorthalidone, Losartan, Clopidogrel bisulfate, Aspirin [acetylsalicylic acid], Pantoprazole for abdominal discomfort, Magnesium oxide for cardiac disorder (all were ongoing). The patient got the second vaccine on 13Feb2021 at 02:30 and felt absolutely fine. The patient went to bed at 10:30 which is pretty typical, the patient got up to go to the bathroom and realized that he was walking really funny. The patient don't have a long walk to bathroom, it just came upon him that he was just walking very fine like his legs were going higher than normal (feet going too high) and kind of falling back down and this was very weird state. The patient thought on that, "it seem to be a neurological symptom". The next day, the patient was just exhausted. The patient came down and laid on the couch and the patient literally could not get his muscles to move properly to get off the couch, the patient just couldn't do it, and patient's wife had to pick him up. The patient stated he was very capable and so for him to be immobilized like that was strange. The patient kept trying to figure out why, why can't he get off this couch. So, that night and the patient slept all day basically and that night the patient slept great. Following day, the patient got up and was still tired and the patient did manage to finally take a shower which he was wanting to do, which worked in the right direction for the patient. The patient also had a rash in his entire torso, thighs, sides and back. The patient stated two things one was that "nerve seemingly neurological thing" and another was that the patient's total upper body had rash and on torso sides and back. The patient denied having rash on arm. The patient had gold tooth and it just started hurting crazy and then after that his mouth was full of like little sores something like that. The patient was able to get rid of them using warm salt water. The patient had lost about 5 pounds. The patient also had headache and fever and he was taking ibuprofen for it. The outcome of the events was unknown.  No follow-up attempts are needed. No further information is expected.