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This is VAERS ID 1490048

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First Appeared on 7/23/2021

VAERS ID: 1490048
VAERS Form:2
Age:
Sex:Unknown
Location:Unknown
Vaccinated:0000-00-00
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-07-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Myocarditis, Pericarditis, Pneumonitis, Contusion

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:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20212

Write-up: Myocarditis/ swelling around my heart on my heart; Pericarditis; Swelling around left lung; My ribs and collar bones feel bruised; This spontaneous case was reported by a consumer and describes the occurrence of MYOCARDITIS (Myocarditis/ swelling around my heart on my heart) and PERICARDITIS (Pericarditis) in a patient of an unknown age and gender who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. No Medical History information was reported. On an unknown date, the patient received second dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) 1 dosage form. On an unknown date, received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (unknown route) dosage was changed to 1 dosage form. On an unknown date, the patient experienced MYOCARDITIS (Myocarditis/ swelling around my heart on my heart) (seriousness criterion medically significant), PERICARDITIS (Pericarditis) (seriousness criterion medically significant), PNEUMONITIS (Swelling around left lung) and CONTUSION (My ribs and collar bones feel bruised). At the time of the report, MYOCARDITIS (Myocarditis/ swelling around my heart on my heart), PERICARDITIS (Pericarditis), PNEUMONITIS (Swelling around left lung) and CONTUSION (My ribs and collar bones feel bruised) outcome was unknown. Not Provided The concomitant medications were not reported. The treatment information was not provided. Very limited information regarding these events have been provided at this time. Further information has been requested.; Sender''s Comments: Very limited information regarding these events have been provided at this time. Further information has been requested.

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