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This is VAERS ID 1040918

History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1040918
VAERS Form:2
Age:
Sex:Male
Location:Florida
Vaccinated:2021-01-16
Onset:2021-01-23
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Injection site pain, Pericarditis

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Acute pericarditis; Soreness on the left shoulder (injection site); A spontaneous report was received from a consumer who was also a 75-years-old, male patient, who received Moderna''s COVID-19 Vaccine (mRNA-1273) and who experienced soreness on the left shoulder (injection site)/ injection site soreness and acute pericarditis/ pericarditis. The patient''s medical history was not provided. Concomitant medications were not reported. On 16 Jan 2021, seven days prior to onset of the events, the patient received their first two planned doses of mRNA-1273 (Batch number: 039K20A) intramuscularly for the prophylaxis of COVID-19 infection. On 23 Jan 2021, the patient experienced soreness on the left shoulder (injection site), tiredness, headache, and chest pain. On 02 Feb 2021, he had difficulty breathing even with his continuous positive airway pressure (CPAP) machine and called 911. He was taken to emergency room (ER) and was diagnosed with acute pericarditis. Treatment included ibuprofen, pantoprazole, and colchicine. Action taken with mRNA-1273 in response to the events was not reported. The outcome of events, soreness on the left shoulder (injection site and acute pericarditis, was not reported.; Reporter''s Comments: This case concerns a 75 year old male subject, who experienced a serious unexpected event of Pericarditis and a non-serious expected event of injection site pain after first dose of mRNA1273 (Lot# 039K20A). Very limited information has been provided regarding the event of pericarditis at this time. Further information has been requested.


Changed on 5/7/2021

VAERS ID: 1040918 Before After
VAERS Form:2
Age:
Sex:Male
Location:Florida
Vaccinated:2021-01-16
Onset:2021-01-23
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Injection site pain, Pericarditis

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Acute pericarditis; Soreness on the left shoulder (injection site); A spontaneous report was received from a consumer who was also a 75-years-old, male patient, who received Moderna''s COVID-19 Vaccine (mRNA-1273) and who experienced soreness on the left shoulder (injection site)/ injection site soreness and acute pericarditis/ pericarditis. The patient''s medical history was not provided. Concomitant medications were not reported. On 16 Jan 2021, seven days prior to onset of the events, the patient received their first two planned doses of mRNA-1273 (Batch number: 039K20A) intramuscularly for the prophylaxis of COVID-19 infection. On 23 Jan 2021, the patient experienced soreness on the left shoulder (injection site), tiredness, headache, and chest pain. On 02 Feb 2021, he had difficulty breathing even with his continuous positive airway pressure (CPAP) machine and called 911. He was taken to emergency room (ER) and was diagnosed with acute pericarditis. Treatment included ibuprofen, pantoprazole, and colchicine. Action taken with mRNA-1273 in response to the events was not reported. The outcome of events, soreness on the left shoulder (injection site and acute pericarditis, was not reported.; Reporter''s Comments: This case concerns a 75 year old male subject, who experienced a serious unexpected event of Pericarditis and a non-serious expected event of injection site pain after first dose of mRNA1273 (Lot# 039K20A). Very limited information has been provided regarding the event of pericarditis at this time. Further information has been requested.


Changed on 5/14/2021

VAERS ID: 1040918 Before After
VAERS Form:2
Age:
Sex:Male
Location:Florida
Vaccinated:2021-01-16
Onset:2021-01-23
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Injection site pain, Pericarditis

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: No adverse event (No reported medical history)
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: Acute pericarditis; Soreness on the left shoulder (injection site); A spontaneous report was received from a consumer who was also a 75-years-old, male patient, who received Moderna''s COVID-19 Vaccine (mRNA-1273) and who experienced soreness on the left shoulder (injection site)/ injection site soreness and acute pericarditis/ pericarditis. The patient''s medical history was not provided. Concomitant medications were not reported. On 16 Jan 2021, seven days prior to onset of the events, the patient received their first two planned doses of mRNA-1273 (Batch number: 039K20A) intramuscularly for the prophylaxis of COVID-19 infection. On 23 Jan 2021, the patient experienced soreness on the left shoulder (injection site), tiredness, headache, and chest pain. On 02 Feb 2021, he had difficulty breathing even with his continuous positive airway pressure (CPAP) machine and called 911. He was taken to emergency room (ER) and was diagnosed with acute pericarditis. Treatment included ibuprofen, pantoprazole, and colchicine. Action taken with mRNA-1273 in response to the events was not reported. The outcome of events, soreness on the left shoulder (injection site and acute pericarditis, was not reported.; Reporter''s Comments: This case concerns a 75 year old male subject, who experienced a serious unexpected event of Pericarditis and a non-serious expected event of injection site pain after first dose of mRNA1273 (Lot# 039K20A). Very limited information has been provided regarding the event of pericarditis at this time. Further information has been requested.

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