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This is VAERS ID 1177803

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1177803
VAERS Form:2
Age:70.0
Sex:Male
Location:Arizona
Vaccinated:2021-03-25
Onset:2021-03-26
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EP6955 / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood albumin decreased, Blood creatine phosphokinase increased, Blood creatine phosphokinase MB, Blood lactic acid, Blood magnesium normal, Blood sodium decreased, Cardiac failure congestive, Dyspnoea, Haematocrit decreased, Haemoglobin decreased, Headache, Insomnia, International normalised ratio increased, Myocarditis, Nausea, Pain, Prothrombin level normal, Red blood cell count decreased, Vomiting, Peripheral swelling, Walking aid user, Drug screen negative, Neutrophil percentage increased, Lymphocyte percentage decreased, Protein urine present, Brain natriuretic peptide increased, Troponin increased, Blood urea nitrogen/creatinine ratio, Urine analysis normal, Metabolic function test normal, Hepatic enzyme abnormal, Immature granulocyte percentage increased, SARS-CoV-2 test negative

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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine 5mg tab qday Fenasteride 5mg tab qday Insulin Aspart Flexpen 15 UNITS with meals Insulin Glargine 30 UNITS bid Losartan 100 mg tab qday Metformin 1000 mg tab bid Simvastatin 10 mg qday Amlodipine 5 mg qday Finasteride 5 mg tab q
Current Illness:
Preexisting Conditions: Diabetes Type II Essential hypertension Hyperlipidemia Hx of abnormal LFTs Hx of microalbuminuria Hx of COVID19 (11/2020)
Allergies: Lisinopril
Diagnostic Lab Data: Urine: normal, trace protein UDS: negative CMP: BUN/CREAT 23.70, Sodium 131, Albumin 3.0, Elevated Liver Enzymes BMP: RBC 4.38, Hemoglobin 12.9, Hematocrit 38.4, NE% 76.1, LY% 14, IG% 0.5 *TROPONIN: 31.860 CK MB: 14.5 CK:716 Lactic Acid normal Magnesium normal *BNP: 2441.5 PT: 12.1, INR 1.15 COVID19: NEGATIVE
CDC 'Split Type':

Write-up: Per triage note of 4/7/2021: "Chief Complaint: pt presents with Nausea & vomitting, ha, body ache, unable to sleep, swollen feet. Symptoms started 3/25 after he recieved his 1st covid vaccine. has had to use a walker and gets SOB. pt had COVID 11/2020" Assessment reveals mild CHF, positive troponin, myocarditis per physician''s notes of 4/7/2021 Patient treated with Zofran 4 mg IV and given 500 ml NS IV then Lasix 40 mg IV. Patient transferred to Medical Center 4/7


Changed on 5/7/2021

VAERS ID: 1177803 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:Arizona
Vaccinated:2021-03-25
Onset:2021-03-26
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EP6955 / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood albumin decreased, Blood creatine phosphokinase increased, Blood creatine phosphokinase MB, Blood lactic acid, Blood magnesium normal, Blood sodium decreased, Cardiac failure congestive, Dyspnoea, Haematocrit decreased, Haemoglobin decreased, Headache, Insomnia, International normalised ratio increased, Myocarditis, Nausea, Pain, Prothrombin level normal, Red blood cell count decreased, Vomiting, Peripheral swelling, Walking aid user, Drug screen negative, Neutrophil percentage increased, Lymphocyte percentage decreased, Protein urine present, Brain natriuretic peptide increased, Troponin increased, Blood urea nitrogen/creatinine ratio, Urine analysis normal, Metabolic function test normal, Hepatic enzyme abnormal, Immature granulocyte percentage increased, SARS-CoV-2 test negative

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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine 5mg tab qday Fenasteride 5mg tab qday Insulin Aspart Flexpen 15 UNITS with meals Insulin Glargine 30 UNITS bid Losartan 100 mg tab qday Metformin 1000 mg tab bid Simvastatin 10 mg qday Amlodipine 5 mg qday Finasteride 5 mg tab q
Current Illness:
Preexisting Conditions: Diabetes Type II Essential hypertension Hyperlipidemia Hx of abnormal LFTs Hx of microalbuminuria Hx of COVID19 (11/2020)
Allergies: Lisinopril Lisinopril
Diagnostic Lab Data: Urine: normal, trace protein UDS: negative CMP: BUN/CREAT 23.70, Sodium 131, Albumin 3.0, Elevated Liver Enzymes BMP: RBC 4.38, Hemoglobin 12.9, Hematocrit 38.4, NE% 76.1, LY% 14, IG% 0.5 *TROPONIN: 31.860 CK MB: 14.5 CK:716 Lactic Acid normal Magnesium normal *BNP: 2441.5 PT: 12.1, INR 1.15 COVID19: NEGATIVE
CDC 'Split Type':

Write-up: Per triage note of 4/7/2021: "Chief Complaint: pt presents with Nausea & vomitting, ha, body ache, unable to sleep, swollen feet. Symptoms started 3/25 after he recieved his 1st covid vaccine. has had to use a walker and gets SOB. pt had COVID 11/2020" Assessment reveals mild CHF, positive troponin, myocarditis per physician''s notes of 4/7/2021 Patient treated with Zofran 4 mg IV and given 500 ml NS IV then Lasix 40 mg IV. Patient transferred to Medical Center 4/7


Changed on 5/14/2021

VAERS ID: 1177803 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:Arizona
Vaccinated:2021-03-25
Onset:2021-03-26
Submitted:0000-00-00
Entered:2021-04-07
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EP6955 / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood albumin decreased, Blood creatine phosphokinase increased, Blood creatine phosphokinase MB, Blood lactic acid, Blood magnesium normal, Blood sodium decreased, Cardiac failure congestive, Dyspnoea, Haematocrit decreased, Haemoglobin decreased, Headache, Insomnia, International normalised ratio increased, Myocarditis, Nausea, Pain, Prothrombin level normal, Red blood cell count decreased, Vomiting, Peripheral swelling, Walking aid user, Drug screen negative, Neutrophil percentage increased, Lymphocyte percentage decreased, Protein urine present, Brain natriuretic peptide increased, Troponin increased, Blood urea nitrogen/creatinine ratio, Urine analysis normal, Metabolic function test normal, Hepatic enzyme abnormal, Immature granulocyte percentage increased, SARS-CoV-2 test negative

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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amlodipine 5mg tab qday Fenasteride 5mg tab qday Insulin Aspart Flexpen 15 UNITS with meals Insulin Glargine 30 UNITS bid Losartan 100 mg tab qday Metformin 1000 mg tab bid Simvastatin 10 mg qday Amlodipine 5 mg qday Finasteride 5 mg tab q
Current Illness:
Preexisting Conditions: Diabetes Type II Essential hypertension Hyperlipidemia Hx of abnormal LFTs Hx of microalbuminuria Hx of COVID19 (11/2020)
Allergies: Lisinopril Lisinopril
Diagnostic Lab Data: Urine: normal, trace protein UDS: negative CMP: BUN/CREAT 23.70, Sodium 131, Albumin 3.0, Elevated Liver Enzymes BMP: RBC 4.38, Hemoglobin 12.9, Hematocrit 38.4, NE% 76.1, LY% 14, IG% 0.5 *TROPONIN: 31.860 CK MB: 14.5 CK:716 Lactic Acid normal Magnesium normal *BNP: 2441.5 PT: 12.1, INR 1.15 COVID19: NEGATIVE
CDC 'Split Type':

Write-up: Per triage note of 4/7/2021: "Chief Complaint: pt presents with Nausea & vomitting, ha, body ache, unable to sleep, swollen feet. Symptoms started 3/25 after he recieved his 1st covid vaccine. has had to use a walker and gets SOB. pt had COVID 11/2020" Assessment reveals mild CHF, positive troponin, myocarditis per physician''s notes of 4/7/2021 Patient treated with Zofran 4 mg IV and given 500 ml NS IV then Lasix 40 mg IV. Patient transferred to Medical Center 4/7

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