Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Body temperature, Cough, Headache, Nasal congestion, Pain
Clinical narrative: cough; nose feels stuffed; fever; body aches; Slight headache; This is a spontaneous report from a contactable other healthcare professional (nurse, patient). A 67-year-old male patient received bnt162b2 (BNT162B2, Solution for injection, Batch/Lot Number: FA6780), via an unspecified route of administration, in left arm (left upper arm) on 19Jul2021 at 11:00 (at the age of 67-years-old) as dose 2, single for COVID-19 immunisation. The patient medical history included ongoing blood cholesterol increased (had since mid 20s, had this condition for about 40 years, it runs in his family, his father has it), COVID-19 from Aug2020 to an unknown date (in the beginning of Aug2020 and was in the hospital until Nov2020. He was in the hospital for 100 days. He was on a ventilator for 30 days. He was really bad. He was out. He did not know what was going on. He knows what it is like when patients don't know what is going on- he states they have to put patients in a semi-induced coma because the vent makes people shake and thrash in the bed and the patient have to be put under. He had not had any COVID tests since Nov202. He used to have weekly COVID tests when he was in the hospital to see if he was carrying COVID. He was always negative for all of the tests. He went to (center name) for the COVID tests. He was in the (center name) every month, they were the ones who did the COVID testing every week. He saw his doctor and had blood work in Jan2021. His doctor did not recommend a COVID test), blood triglycerides increased from an unknown date and unknown if ongoing and bad allergies (takes Singulair for this). The patient previously received first dose of bnt162b2 (BNT162B2, Solution for injection, Batch/Lot Number: EW0217, Expiration date: Unknown), via an unspecified route of administration in left arm (left upper arm) on 28Jun2021 at 11:30 as dose 1, single for COVID-19 immunisation. The patient concomitant medications included atorvastatin (LIPITOR) 40 mg taken for blood cholesterol from an unspecified start date and ongoing (been on it for about 40 years); fenofibrate (TRICOR [FENOFIBRATE]) 160 mg taken for blood triglycerides increased from an unspecified start date and ongoing (been on it for about 20 years). He got the flu shot every year and had the pneumonia shot and had no reactions. He did not do the shingles shot, he might. The patient did not receive other vaccines the same day or within 4 weeks prior to COVID vaccination. On 20Jul2021, the patient experienced fever, body aches, slight headache, and cough, nasal stuffiness on an unspecified date. Patient reported that he received his second dose yesterday on 19Jul2021 and is having the same symptoms as first dose now but thinks they may be already improving. Caller stated his nose feels stuffed and when he takes his medication it usually keeps it clear, but it is still there and he thinks maybe it is allergies. The patient received treatment as Tylenol for all events taken every 4 hours. The patient was afraid to give Pfizer's drugs because he has had so many bad experiences with Pfizer. He stated that Pfizer was doing bad things and was getting all this money and doing all this crap to people and Pfizer cannot even answer a question. He took Tylenol for fever and it got rid of it. He knows these symptoms are normal because he had a neighbour that had the vaccine and he was tired from it. Caller also states he knows people that have had this and supposedly the vaccine was doing its job. He clarified further his fever was not that high, it was only 101, and it was not like its escalating. The following day it went away, just like that. He confirms by the 16Jun2021, he was fine. He had fever, chills and headache with the first dose. With the second dose he had the same thing except no chills. What has happened is that he has allergies and he is getting a cough every couple of hours. Caller confirms he got the second COVID shot yesterday and the first shot 3 weeks ago. He figured if he got a fever and all, it was normal and goes away in a day and half, and he is usually fine. He is just concerned about the cough. He is not coughing every hour, its just like every 4 or 5 hours, he does not know if that a concern or not. With the second dose, Caller confirms he has a fever. His fever started in the middle of the night at 03:00AM with the body aches and slight headache. He confirms he had no chills. The body aches woke him up. He didnt know he had a fever, he was not sweaty, but he figured he might as well check his temperature and it was only 101 degrees, its not like it was high. He clarifies he checked his temperature at 03:00. He states his back was so bad from the body aches. He states the body aches are better now because the Tylenol is probably helping. His current fever after having the second dose is staying the same at 101 degrees, its not getting any higher or going down. He is sure by tomorrow it will be gone. He would be more concerned if his temperature was at 103 or 104, he is not really concerned at 101 degrees. He confirms the headache is improving with the Tylenol. He is not currently working but since he had COVID so bad to where he almost died, he was afraid he might get it again. He confirmed with the second dose, his headache was not as bad as it was with the first dose. He confirmed the date of his second dose was 19Jul2021. The patient underwent lab tests and procedures which included body temperature 101 101 degrees on 20Jul2021. The outcome of the events headache was resolved in 2021. Outcome of event fever was not recovered. Outcome of events body ache, slight headaches was recovering and outcome of other events cough, nose feels stuffed was unknown.   The reporter assessed the fever, and headache to be related to bnt162b2 (Method of assessment: Global introspection).  Information about lot/batch number requested.  Follow-up (20Jul2021): New information received from a contactable nurse included: patient details (height, weight and ethnicity was added), vaccine facility info updated and best HCP info updated, event (cough, nasal stuffiness) added and narrative updated.  Follow-up attempts are completed. No further information is expected.