Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: Brain injury, Cerebrovascular accident, Dizziness, Electrocardiogram, Electroencephalogram
Clinical narrative: pounding headache; dizziness; fever; swollen painful glands; sharp pain in my head/ear; could not remember my 4yr old grand-son name; stroke; brain damage; This is a spontaneous report from a contactable consumer, the patient. A 56-year-old female patient received BNT162B2 solution for injection (lot EN5318, second dose) intramuscular in left arm on 24Apr2021 at 11:00 (at the age of 56-years-old) as a single dose for COVID-19 immunization. Medical history included Former smoker (packs: 1, years: 30, quit date: 10Feb2010, type: cigarettes), alcohol, asthma, depression, Hypothyroidism, Recurrent herpes labialis, headaches (rare headaches , Mid fontal area, throbbing, lasted constantly, continuous resolved), dizziness, migraines (used to get funny smells like orange, metal, gets headache, never passes out), Pregnancy from 1982 to 1988, cognitive problems (had some sharp pain in right occipital area radiating to right ear, moving pain, severe pain, lasted few minutes) in May2021, allergies (milk, mold, feathers, sulfa, trees, fish derived, shellfish derived, wheat, dust mites, cats, dogs), possible stroke, aseptic meningitis, eyeglasses wearer, sinus problems, cold or heat tolerance, and concussion in past. Concomitant medications included estrogens conjugated (PREMARIN), acyclovir, levothyroxine, epinephrine, budesonide/formoterol fumarate (AEROVIAL), salbutamol (ALBUTEROL HFA), pseudoephedrine, cyanocobalamin, calcium, acetylsalicylic acid (aspirin), indomethacin, and minerals/vitamins (BLACKMORES MULTIVITAMINS AND MINERALS). Family history included cancer and pituitary benign tumor (mother), cirrhosis (father). Past drug history included allergies to BACTRIM and erythromycin. Historical vaccine included BNT162B2 (first dose) for COVID-19 immunization on 03Apr2021. In Apr2021, the patient experienced pounding headache, dizziness, fever, swollen painful glands, sharp pain in my head/ear, and could not remember my 4yr old grand-son name. In 2021, the patient experienced stroke and brain damage. Lab tests included EKG in 2021: this is essentially an unremarkable electroencephalogram with no evidence of eliptiform abnormalities or electrographic seizures; Neurologist consult on 21Aug2021 unknown results; MRI Brain on 30Aug2021 Abnormal smell, had multiple Hx of concussion in past, c/o abnormal smell, r/o partial seizures; EEG on 31Aug2021 in the most alert stage, there is moderate amount of front central activity beta activity which is noted bilaterally symmetrically. ENT: Negative for Trouble Swallowing. Negative for Nose Bleeds, Negative for Dentures. Positive for Sinus Problems; Cardiac: Negative for Chest Pain, Negative for Irregular Heartbeat. Negative for Heart Failure, Negative for Angina. Negative for Murmur, Negative for High Blood Pressure. Negative for Pain in legs w/exercise, Negative for Blood Clots, Negative for Leg Swelling; Respiratory: Negative for Shortness of Breath, Negative for Cough/heezing, Positive for Asthma. Negative for Other Lung Problems; Hemel/Lymph: Negative for Swollen Nodes/Glands. Negative for Bleeding Problems, Negative for Anaemia; GI: Negative for Negative for Blood in Stool. Negative for Diarrhea, Negative for Intestinal Bleeding, Negative for Poor Appetite, Negative for Hiatal Hermia, Negative for Ulcer, Negative for Haemorrhoids, Negative for Vomiting/Nausea, Negative for Constipation; G/U: Negative for Pain/Burning, Negative for Urinary Frequency/Urgency, Negative for Blood in urine, Negative for Slow or Small Stream, Negative for Poor Bladder Emptying, Negative tor up at Night to Urinate, Negative for Sexual Dysfunction; Endo: Positive for Cold or Heat Intolerance, Negative for Hot Flashes/Flushing, Negative for Abnormal Thirst. Negative for Change in Body Hair; Skin: Negative for Lumps or Nodules, Negative for Breast Lumps, Negative for Rashes/Sores; Psych: Positive for Depression/Anxiety. Musculoskeletal: Negative for Joint Replacement. Negative for Broken Bones. Physical exam was as follows: Constitutional: She is oriented to person, place, and time and wen-developed, well nourished, and in no distress. No distress.HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Mouth/Throat: No oropharyngeal exudate. Eyes: Conjunctivae and EOM are normal. Pupils are equal. round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. Neck: Normal range of motion. Neck supple. Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. The outcome of the event headache was recovered in 2021. The outcome of the other events was unknown.  Follow-up attempts are completed. No further information is expected.