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From the 7/23/2021 release of VAERS data:

This is VAERS ID 1309631



Case Details

VAERS ID: 1309631 (history)  
Form: Version 2.0  
Age: 21.0  
Sex: Female  
Location: Iowa  
Vaccinated:2021-04-28
Onset:2021-05-02
   Days after vaccination:4
Submitted: 0000-00-00
Entered: 2021-05-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 LA / -

Administered by: Public       Purchased by: ?
Symptoms: Myocarditis, SARS-CoV-2 test
SMQs:, Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad), COVID-19 (broad)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Comments: List of non-encoded Patient Relevant History: Patient Other Relevant History 1: None
Allergies:
Diagnostic Lab Data: Test Date: 20210502; Test Name: Nasal Swab; Test Result: Negative
CDC Split Type: USPFIZER INC2021499995

Write-up: myopericarditis; This is a spontaneous report from a contactable consumer (patient). A non-pregnant 21-year-old female patient received the second dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Solution for injection), via an unspecified route of administration, administered in left arm on 28Apr2021 at 13:00 (at 21 years old, no pregnant, Batch/Lot number was not reported) as a single dose for covid-19 immunization. The patient medical history was not reported. No other medical history and no known allergies. The patient not had Covid prior vaccination. The patient previous took the first dose of BNT162B2 (PFIZER-BIONTECH COVID-19 VACCINE, Solution for injection), via an unspecified route of administration, administered in left arm on 07Apr2021 at 13:00 (at 21 years old, no pregnant, Batch/Lot number was not reported) as a single dose for covid-19 immunization. The patient''s concomitant medications were not reported. The patient was ended up in the hospital with myopericarditis on 02May2021 at 06:45AM. Patient was a health 21 years old who had no heart problems before. Also had no heart problems in the family. The event was resulted in Emergency room/department or urgent care, Hospitalization, Life threatening illness (immediate risk of death from the event). Hospitalized 1 day. Prescribed colchicine and metoprolol for event. The patient underwent lab tests and procedures which included SARS-CoV-2 test (Nasal Swab): negative on 02May2021. The outcome of the event was recovering. Information about the Lot/batch number has been requested.


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