Age: 85.0
Sex: F
Vaccine: COVID19
Symptoms: Blood creatine phosphokinase, Blood culture, Blood urine present, Body temperature, Chest X-ray
Clinical narrative: Traumatic rhabdomyolysis S/P Fall; Traumatic rhabdomyolysis S/P Fall; I had two days of blood in my urine; The initial case was missing the following minimum criteria: unspecified suspect product. Upon receipt of follow-up information on 08Feb2022, this case now contains all required information to be considered valid.  This is a spontaneous report received from a contactable reporter(s) (Consumer or other non HCP). The reporter is the patient.  An 85 year-old female patient received bnt162b2 (BNT162B2), administration date 04Feb2021 (Lot number: EW5318) at the age of 85 years as dose 2, single for covid-19 immunisation. Relevant medical history included: "asthma" (unspecified if ongoing); "Obesity" (unspecified if ongoing); "CAD" (unspecified if ongoing); "bad kidney" (unspecified if ongoing). The patient's concomitant medications were not reported. Vaccination history included: Bnt162b2 (1st dose, Lot Number: EK9231, Pfizer), administration date: 14Jan2021, when the patient was 85 years old, for COVID-19 Immunization. The following information was reported: RHABDOMYOLYSIS (hospitalization), FALL (hospitalization) all with onset 05Feb2021, outcome "unknown" and all described as "Traumatic rhabdomyolysis S/P Fall"; BLOOD URINE PRESENT (non-serious), outcome "unknown", described as "I had two days of blood in my urine". The patient was hospitalized for rhabdomyolysis, fall (start date: 09Feb2021, discharge date: 23Feb2021, hospitalization duration: 14 day(s)). Consumer stated, she collapsed on the floor, paralyzed, and was taken to the hospital and they put the name (Incomplete sentence). She was urinating on the toilet went to get ugs, could not move, down to the floor (bathroom quit came to door and told her to call ambulance. She had a bad kidney and didn't tell anybody she had a bad kidney and whatever it was, she was bleeding and went into an attack and the name of it was called Rhabdomyolysis, that's the name of what doctor said she had. All her muscles were paralyzed. That's why she just want to. She was thinking about people that have kidney problems and stuff like that. That's what she was thinking about and right now, she was in the hospital. She had been there for 5 days, she left the hospital, went to rehab for two weeks. And after rehab, She have 5 weeks of home rehab and then she have to go back and go on. Her body would be strong enough to go on the machines. Consumer stated, her question would be she really like to be (incomplete sentence), the issue was she had bad kidney and she didn't think of the bad kidney, the poison, she had two days of blood in her urine. The reported issue occurred after use of a Pfizer product. In the Feb2021 had her second Covid Pfizer. She collapsed on the floor, paralyzed and was taken to the hospital, with date started on 05Feb2021. All her muscles were paralyzed on 05Feb2021. It was reported a diagnosis of traumatic rhabdomyolysis S/P fall with date of admission 09Feb2021 and date of discharge 23Feb2021. Patient was discharged home with home physical therapy for continued functional progress. The patient was admitted to hospital for comprehensive multidisciplinary inpatient rehabilitation following Traumatic Rhabdomyolysis S/P Fall to (Name) 06Feb2021. The patient on 05Feb2021 went to Emergency room by ambulance was admitted to hospital 06Feb2021. The discharge course was follows: The patient was a fall secondary to weakness and inability to get off the floors for 3 hours. On EER presentation patient noted febrile to 102.6, however negative covid PCR and unremarkable CXR. Lab works was significant for transsaminitis with elevated CK 1109 along procalcitonin of 0.7. Imaging included a CT head was done showing no acute findings. Patient seen and examined in the emergency department (ED) in no acute distress, bruishing noted on the tricep region of right upper extremity, patient received 1 L NS by ER provider. Patient was diagnosed with traumatic rhabdomyolysis with transminitis but no AKI due to generalized weakness, treatmetn with IVF CK initially elevated at 1109, today improved to 842. Patient was noted to have a fever on admission. Covid negative, blood cultures NGTD UA and chest X-ray, negative as well. Likely reactive in nature. CDA cont ASA, Metoprolol, was not getting Plavix in the Hospital, Heparin SQ. Patient was deemed medically stable and transferred to Rehab (Name) for MDR. After (Name) stay at hospital, the patient went to Rehabilitation(Name). The Patient's hospital course at (Name) was noted for improved pulse oximetry, 88% only. Continue CPAP with oxygen overnight. The remainder of patient stay at (Name) was uncomplicated. The patient participated in physical therapy and occupational therapy programs. Patient received rehabilitative nursing care and pain management. Patient progress was discussed at the multidisciplinary team conference and discharge plan was made according to the rehabilitation goals. Please refer to rehabilitation progress notes for details. Consultations: Psychology.  Follow-up attempts are completed. No further information is expected.