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This is VAERS ID 1463696

History of Changes from the VAERS Wayback Machine

First Appeared on 7/16/2021

VAERS ID: 1463696
VAERS Form:2
Age:15.0
Sex:Male
Location:Colorado
Vaccinated:2021-06-28
Onset:2021-07-01
Submitted:0000-00-00
Entered:2021-07-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 2 RA / SYR

Administered by: Pharmacy      Purchased by: ??
Symptoms: Echocardiogram, Electrocardiogram, Myocarditis, Ultrasound scan, Blood test, Blood pressure measurement

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Ibuprofen
Current Illness: no
Preexisting Conditions: no
Allergies: no
Diagnostic Lab Data: 7/2/2021 - EKG, Ultra sound, echocardiogram, blood pressure, blood tests, oxygen level 7/3/2021 - EKG, echocardiogram, blood pressure, blood tests, oxygen level 7/2/2021 - EKG, echocardiogram, blood pressure, blood tests, oxygen level 7/2/2021 - EKG, echocardiogram, blood pressure, blood tests, oxygen level 7/2/2021 - EKG, echocardiogram, blood pressure, blood tests, oxygen level
CDC 'Split Type':

Write-up: PT had myocarditis as a result of the second dose of the vaccine. He spent 5 days at Hospital.

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