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This is VAERS ID 1384880

History of Changes from the VAERS Wayback Machine

First Appeared on 6/11/2021

VAERS ID: 1384880
VAERS Form:2
Age:22.0
Sex:Female
Location:Michigan
Vaccinated:2021-06-04
Onset:2021-06-04
Submitted:0000-00-00
Entered:2021-06-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 049C21A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Anaphylactic reaction, Confusional state, Dizziness, Erythema, Pruritus, Rash pruritic

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Systemic: Allergic: Anaphylaxis-Medium, Systemic: Allergic: Itch (specify: facial area, extremeties)-Mild, Systemic: Allergic: Rash (specify: facial area, extremeties)-Mild, Systemic: Confusion-Medium, Systemic: Dizziness / Lightheadness-Medium, Additional Details: Patient noticed redness and itching on chest approximately 20 minutes after injection but no other reported symptoms. Patient had already had a hive like rash on arm prior to injection. Patient was advised to stay in store for further observation. After an hour of observation patient denied any further new symptoms and departed. She was advised to stay near town and to call 911 if she developed any other symptoms. Patient called 911 approximately 2 hours after departure and was taken to ER.

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