Age: 87.0
Sex: M
Vaccine: COVID19
Symptoms: Respiratory syncytial virus test, SARS-CoV-2 test, Troponin T, Urine analysis
Clinical narrative: pyrexia; Was unable to stand; This is a spontaneous report from a contactable consumer (Patient). A 87-years-old male patient received BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, Formulation: Solution for injection, Lot number: ER8733), via intramuscularly in arm left on 29Mar2021 at 08:00 AM age at time of vaccination as 87 years-old, as a dose 2, single for COVID-19 immunisation. The patient's medical history included ongoing type 2 diabetic, ongoing hbp, ongoing congestive heart failure and COVID-19, on an unspecified date in 2020, not going, the patient was hospitalized for 10 days and recovered. His treatment did not necessitate ventilation. Historical vaccine included BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, Formulation: Solution for injection, Lot number: EN6205), via intramuscular in arm left (left upper arm) on 05Mar2021 at morning as a dose 1, single for COVID-19 immunisation and within 12 h experienced low grade fever, was unable to stand and ambulance transported to emergency room. Released within 7 hr and underwent lab tests (Sepsis Lactate with reflex, XR Chest 1 Vw, differential auto, ECG 12-lead, cbc w/ auto differential, EGFR, comprehensive metabolic panel, resulted as unknown results), on 06Mar2021. The patient's concomitant medications included brimonidine tartrate (ALPHAGAN P), 0.1% drops, 2x/day (1 drop into both eyes 2 times a day, morning and evening) intraocular on 01Apr2021, ascorbic acid 250 mg tablet (commonly known as Vitamin C), 1x/day (morning), oral on 02Apr2021, acetylsalicylic acid (ASPIRIN (E.C.), 81 mg, 1x/day (morning), oral on 02Apr2021, atorvastatin (commonly known as Lipitor), 40 mg, 1x/day (nightly, bedtime), oral on 01Apr2021, carvedilol (commonly known as Coreg), 3.125 mg, 2x/day (with meals, morning and evening), oral on 01Apr2021, cetirizine (commonly known as Zyrtec), 10 mg, 2x/day (dinner and bedtime, morning and bedtime), oral on 01Apr2021, cholecalciferol vitamin D3 2000 units, 1x/day (morning), oral on 02Apr2021, copper gluconate, 2 mg, 4x/day (morning), oral on 02Apr2021, Cyanocobalamin (commonly known as Vitamin B12), 1000 ug/ml, cyclic, intramuscular once a month on an unspecified date, fexofenadine (commonly known as Allegra), 180 mg, 1x/day (morning), oral on 02Apr2021, fish oil, 1 capsule, 2x/day (morning and evening), oral on 01Apr2021, furosemide, 20 mg, 1x/day (morning), for leg swelling, oral on 02Apr2021, Gabapentin (commonly known as Neurontin), 300 mg, 1x/day (nightly, bedtime), oral on 01Apr2021, glipizide (GLIPIZIDE XL), 2.5 mg, 2x/day (morning and evening), oral on 01Apr2021, ketoconazole, 2 % as needed, topical on an unspecified date, latanoprost (commonly known as Xalatan), 0.005 % 1 drop (nightly, bedtime), intraocular on 01Apr2021, metformin 500 mg, 2x/day (morning and evening) with meals, oral on 01Apr2021, polyethylene glycol 3350, 17 g, as needed upto 30 doses, oral on an unspecified date for constipation, sacubitril;valsartan (commonly known as Entresto), 0.5 mg, 2x/day (morning and evening), oral on 01Apr2021, triamcinolone (commonly known as Kenalog), 0.1 %, 2x/day, topical on an unspecified date for irritation or rash, mirabegron (MYRBETRIQ), 50 mg, daily, oral on 02Apr2021, multivitamin capsule, 1 capsule/day (morning), oral on 02Apr2021. BD Luer- Lok Syringe, blood glucose diagnostic strip, blood glucose meter, lancets misc, used to check blood sugar daily morning. Prior vaccinations within 4 weeks was reported as none. It was reported that, the patient experienced on two occasions a reaction of Covid-19 vaccination. The patient was diagnosed with Covid-19 on an unspecified date in 2020. He was hospitalized for 10 days and recovered. His treatment did not necessitate ventilation. The patient dosed with second dose in left upper arm on 29Mar2021, within 12 hr, the patient was running a low-grade fever (+101) and was unable to stand and ambulance transported to emergency room. Admitted to hospital giving rise to a 3 day stay. Test was completed and patient was given the medication. The patient was hospitalized from 30Mar2021 to 02Apr2021. Treatment was not received for the events. On an unspecified date in Mar2021, the patient underwent lab tests and procedures which included fever, resulted as 101+ and on 30Mar2021, POCT GLUCOSE DEVICE, XR Chest 1 Vw, DIFFERENTIAL AUTO, CBC W/ AUTO DIFFERENTIAL, EGFR, resulted as unknown results, INFLUENZA A/B, RSV, COVID-19 PCR, resulted as negative, Troponin T, resulted as high-sensitivity 4 & 6-hour, urinalysis, resulted as unknown results, microscopic. The outcome of the events was recovered on 02Apr2021.  Follow-up attempts are completed. No further information is expected.