Age: 84.0
Sex: M
Vaccine: PNC13
Symptoms: Insomnia, Lacrimation increased, Lipids normal, Metabolic function test normal, Neurological examination normal
Clinical narrative: This is a spontaneous report from a contactable chronic care coordinator reporting on behalf of a physician and from a contactable physician. An 84-year-old male patient received PREVNAR 13 (Lot # M51192, Expiration Date May 2017), intramuscular in left deltoid on 24Feb2016 09:55 at 0.5 ml, single. Medical history included ongoing hypertension, ongoing high cholesterol and ongoing overactive bladder; prostate cancer, sciatica, radiation for Proctitis, mild cognitive impairment, hyperlipidaemia and internal bleeding haemorrhoids; colonoscopy in Jan2004, prostate surgery in 2000, hip replacement in 2002, polyp removed in 2001; malignant neoplasm of prostate. Concomitant medications included amlodipine (tablet) oral at 5 mg 1x/day for blood pressure, gabapentin (capsule) oral at 300 mg 3x/day, lovastatin (tablet) oral at 400 mg 1x/day for high cholesterol, MYRBETRIQ, (tablet) oral at 25 mg daily for overactive bladder, FLONASE, (nasal spray) nasal 50 ug, 1x/day, 2 sprays each nostril, Vitamin B-12, (tablet) oral at 100 ug once daily, amlodipine besylate (tablet, 5 mg) 1 tablet once a day, lorazepam (0.5 tablet) oral 1 tablet twice daily, ANUCORT-HC, (25 mg suppository) 1 suppository twice a day, ranitidine (150 mg tablet) 1 tablet every 12 hrs, amoxicillin (500 mg capsule) 1 capsule three times a day (TID), all ongoing. On 25Feb2016 the patient experienced pressure in head, sneezing, coughing, no appetite, watery eyes, loss of sleep and greenish mucous all with outcome of not recovered; lack of taste with outcome of unknown. The patient went to the doctor's on 08Mar2016 reporting all of the events. The adverse events required an emergency room or physician visit, but the patient was not admit to hospital. Specific tests and/or treatment were not require. According to physician notes, the side effects reported might due to acute bronchitis however the reporter was asked to call and ask if these events could be related to the vaccine. The patient underwent lab tests on 29Feb2016 including CMP, lipid profile, and urinalysis and everything was normal; the patient underwent chest X-Ray on 08Mar2016 but no results were provided. The patient was found to have Temp 97.9 F, BP 137/80 mm Hg, BMI 24.86, HR 64, Oxygen sat % 98. Examination showed: HEENT: Head -normocephalic/atraumatic. Carotid Upstroke: normal, no bruit. JVD: none. Heart: regularly irregular rhythm, normal S1S2, no S3, no S4. Heart Murmur: none. Lungs: R middle lobe and Rl; t crackles; otherwise clear. Abdomen: soft, non-tender, no organomegaly, no masses palpated, no bruits. Extremities: no leg edema, normal pedal pulses. Peripheral Pulses: normal. Neurologic: grossly intact. Mood: euthymic. The patient provide information to physician regarding the reported adverse events with the use of PREVNAR 13 and the physician did not consider that PREVNAR 13 had a causal effect to the adverse events. Follow-up (18Apr2016): New information reported from a contactable physician includes: PREVNAR 13 details updated, events details provided, concomitant medications and lab data added, physician acknowledgment of the occurrence of the events and causality assessment provided. Follow-up attempts completed. No further information expected.