Age: 74.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Lethargy, Malaise, Musculoskeletal stiffness, Myalgia, Nasal injury
Clinical narrative: general sense of weakness; Short of breath; bum knee and nose; bum knee and nose; covid insomnia; nose bleeds; His knee was really a beautiful shade of purple; couldn't move fast enough to get one foot in front of the other; pounding headache; muscle pain and joint pain; lethargy; general tiredness; brain fog; muscle aches and chills; muscle aches and chills; Feeling unwell; lost his balance; fell; dizziness and stiffness; dizziness and stiffness; This is a spontaneous report from a contactable consumer (patient). A 74-year-old male patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE; Formulation: Solution for injection; Lot number: ER8732) via an unspecified route of administration at right shoulder on 27Mar2021 as single dose for covid-19 immunization.   The patient concomitant medications includes, zolpidem tartrate (AMBIEN CR 12.5mg) still ongoing for insomnia, taking it from years as patient comes from family of insomniacs & high-pressure jobs; triazolam (HALCION) (0.25mg) still ongoing for sleep, rivaroxaban (XARELTO) (20mg) started taking in 2012 for pulmonary embolism & has been on blood thinners, aspirin acetylsalicylic acid (low dose aspirin of 65mg) for supplemental blood thinner still ongoing. Patient has history of seasonal allergies and its prime time right now so its compounding. Relevant medical history includes, both knee replacement, pulmonary embolism, bad blood pressure problems maybe 5 years ago all on an unspecified date. The patient historical vaccine included the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 mRNA VACCINE, Lot number: EN6198), at Right shoulder on 06Mar2021 as single dose for covid-19 immunization.  On 27Mar2021, When the patient got home from his shot, he had no problems at all and he went to bed. Being an old guy, he got up in the middle of the night to use the bathroom and he lost his balance and took a nasty fall, so has a bummed up knee and stuff too, so that is what aggravates it. He clarifies he has a bum knee and nose after having the fall. Since he took the fall and has the bum knee, it is kind of a chore going up and down stairs.  On 28Mar2021 the patient experienced general sense of weakness , general tiredness. It has been over a week and he wants to know if that is unusual. Patient adds there was kind of a brain fog thing From: 28 Mar 2021  going on. The brain fog concerns him because he has to get his taxes done. He was still having trouble with the nose bleeds, which sort of compounds his misery, but he is getting better. It seems the side effects are getting incrementally better every day, but its not like he wakes up and its completely gone. It's like some prolonged illness. His side effects are getting marginally better. He is fairly clear headed today and he even had the nerve to take a short drive to the supermarket and stuff, although he wouldn't want to drive cross country in terms of being able to concentrate. But doing his taxes, will take a little work. Patient stated in the beginning he had muscle aches and chills from: 28Mar2021, but that went away after a day or two. Patient stated he had muscle aches/chills for a couple of days. He feels he has recovered completely as far as he knows. He never had nausea. On an Unspecified date patient mentions feeling a little short of breath, but states that could be more of the asthma thing. He does not recall having injection site pain at all. The tiredness is definitely ongoing, but has improved. He clarifies it has probably improved incrementally but doesn't really want to classify it as improvement because it might be temporary. He did not have a headache until he was waiting on the phone to speak to this call handler. On 28Mar2021 the patient experienced muscle pain for a few days and that sort of cleared up. This was the same with joint pain. After the big bang, clarified as the fall, everything proceeded. He still feels the muscle and joint pain, only in his knee, but its starting to fade. His knee was really a beautiful shade of purple, but it seems to be fading and hurting less so that is recovering, too. This pain is secondary. The side effect was the dizziness, stiffness, and inability to keep his balance. Caller states he was stiff as a board and he just couldn't move fast enough to get one foot in front of the other, and he landed on his knee, so the pain in his knee was not directly caused by shot. He felt fine at the center where he took the shot. He had to wait 15-20 minutes after the shot. He felt fine, drove home, went to bed, and in the middle of the night, it all started. He still feels a little dizzy and unsure and has been using a cane. He got both knees replaced and is worried that he damaged the actual replacement joint as opposed to just the muscle tissue. He just doesn't trust himself without the cane. He hasn't fallen over and hasn't passed out. He feels stiff all over but that could be from not getting to the gym and working out and not doing his regular work outs. Patient stated that the lethargy might be slightly better. He was making himself do more but he still gets really tired and it was really hard for him to get motivated, like to get out of the chair and go downstairs. He went to the supermarket and had to unload his car in stages- he took the perishables out and rested for a while and then went back out and got another couple of bags and then rested again. He just could not work straight through like he normally does. States he is in pretty good shape normally. He does not feel particularly great and that is the reason that he called to find out if this should last this long. Patient stated that he does have high blood pressure and heart problems. In fact at the end of the month, he will be going in for a catherization with Dr. (Name) so that was another reason he wants to have this stuff cleared up and out of the way. He still has dizziness and weakness. Patient stated that last night was the first night of decent sleep he had got. He has insomnia actually and he takes two sleep medications, but even taking those and washing it down with a glass of wine, he could not sleep for a whole week. He clarifies even with the Halcion and Ambien CR, it didn't work for a whole week- he could not sleep which adds to the brain fog. Typically, he goes to sleep, wakes up after a couple of hours, and then he is awake so he reads for a few hours and then takes the second medication and then sleep the rest of the night. He ends up getting a full 8-9 hours of sleep normally and he did that last night.   On 08Apr2021 he developed a pounding headache but it was probably independent of the shot. He took Tylenol and he is okay now, but he just thought it was ironic that he had one while waiting to talk to Pfizer when he hadn't had one before. Outcome of the events muscle pain and joint pain, dizziness and stiffness, Feeling unwell were ongoing and those of other events were unspecified.  No further information was provided or obtained