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VAERS ID: 1327043

AGE: 14| SEX: M|State: CA

Description

Pt receive the vaccination at 1147, immediately after administration pt has syncopal episode where patient was able to regain consciousness within 30 seconds. Pt able to answer questions appropriately. Vital signs were taken - WNL, STAT RN was called, ice pack applied behind neck, apple juice and granola bar given to pt. Pt assessed and was a&0x4. Pt states he was very anxious about vaccine. Pt transferred to gurney and taken to treatment room for further observation due to pt sweating perfusely a few minutes after syncopal episode. Report given to RN in treatment room at 1210. Pt's mother at bedside and even at all times:

Symptoms

Anxiety, Hyperhidrosis, Immediate post-injection reaction, Loss of consciousness, Syncope

Vaccines

VAX DATE: 17 May 2021 | ONSET DATE: 17 May 2021 | DAYS TO ONSET: 0
Vaccine TypeManufacturerVaccine NameDoseRouteSiteLot
  • COVID19
  • PFIZERBIONTECH
  • COVID19 (COVID19 (PFIZER-BIONTECH))
  • 1
  • IM
  • LA
  • ew0173

RECVDATE:17 May 2021
CAGE_YR:14
CAGE_MO:
RPT_DATE:
DIED:
DATEDIED:
L_THREAT:
ER_VISIT:
HOSPITAL:
HOSPDAYS:
X_STAY:
DISABLE:
RECOVD:U
LAB_DATA:n/a
V_ADMINBY:PVT
OTHER_MEDS:N/A
CUR_ILL:N/A
HISTORY:N/A
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:2
TODAYS_DATE:17 May 2021
BIRTH_DEFECT:
OFC_VISIT:Y
ER_ED_VISIT:
ALLERGIES:PENICILLIN
V_FUNDBY:
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