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This is VAERS ID 1336767

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History of Changes from the VAERS Wayback Machine

First Appeared on 6/4/2021

VAERS ID: 1336767
VAERS Form:2
Age:19.0
Sex:Female
Location:Illinois
Vaccinated:2021-04-03
Onset:2021-04-30
Submitted:0000-00-00
Entered:2021-05-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: School      Purchased by: ??
Symptoms: Bradycardia, Cardiac arrest, Cardiogenic shock, Dizziness, Myocarditis, Pyrexia, Oropharyngeal pain

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
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: Cetirizine
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient presented 5/16/2021 with 1 week dizziness, fever and sore throat, found to have acute myopericarditis c/b cardiogenic shock and bradycardic arrest.


Changed on 6/25/2021

VAERS ID: 1336767 Before After
VAERS Form:2
Age:19.0
Sex:Female
Location:Illinois
Vaccinated:2021-04-03
Onset:2021-04-30
Submitted:0000-00-00
Entered:2021-05-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / -

Administered by: School      Purchased by: ??
Symptoms: Bradycardia, Cardiac arrest, Cardiogenic shock, Dizziness, Myocarditis, Pyrexia, Oropharyngeal pain

Life Threatening? Yes
Birth Defect? No
Died? No Yes
   Date died:0000-00-00
Permanent Disability? Yes
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: Cetirizine
Current Illness: None
Preexisting Conditions: None
Allergies: None
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient presented 5/16/2021 with 1 week dizziness, fever and sore throat, found to have acute myopericarditis c/b cardiogenic shock and bradycardic arrest.

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