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This is VAERS ID 1017339

History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1017339
VAERS Form:2
Age:88.0
Sex:Male
Location:Florida
Vaccinated:2021-01-30
Onset:2021-02-05
Submitted:0000-00-00
Entered:2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K208 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Cyanosis, Dyspnoea exertional, Laboratory test abnormal, Respiratory arrest, Troponin increased, Acute kidney injury, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-05
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Furosemide Lasix, 20 mg PO daily at 0600 Simvastatin 20 mg Tablet PO daily Amlodipine Norvasc 2.5 mg Tablet PO daily Tamsulosin HCl 0.4 mg Capsle PO daily Dutasteride 0.5 mg Capsule PO daily Metroprolol Tartrate Lopressor 25 mg Tablet PO on
Current Illness: sob with exertion, started just prior to vaccine
Preexisting Conditions: A-fib Bladder cancer history CKD COPD HTN
Allergies: Penicillin hives Sulfonamide Antibiotics hives
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Admitted to hospital with sob upon exertion that started prior to vaccine. Hx COPD, HTN, CKD, hyperlipidemia, bladder cancer in remission. Stated he has been taking Eliquis and Xarelto between renal doctor and cardiologist Dr. Anticipating going home 2/5/21 but then turned blue and stopped breathing under a DNR. COVID test negative. Labs show acute on chronic renal failure with an elevated troponin likely from demand ischemia.


Changed on 5/7/2021

VAERS ID: 1017339 Before After
VAERS Form:2
Age:88.0
Sex:Male
Location:Florida
Vaccinated:2021-01-30
Onset:2021-02-05
Submitted:0000-00-00
Entered:2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K208 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Cyanosis, Dyspnoea exertional, Laboratory test abnormal, Respiratory arrest, Troponin increased, Acute kidney injury, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-05
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Furosemide Lasix, 20 mg PO daily at 0600 Simvastatin 20 mg Tablet PO daily Amlodipine Norvasc 2.5 mg Tablet PO daily Tamsulosin HCl 0.4 mg Capsle PO daily Dutasteride 0.5 mg Capsule PO daily Metroprolol Tartrate Lopressor 25 mg Tablet PO on
Current Illness: sob with exertion, started just prior to vaccine
Preexisting Conditions: A-fib Bladder cancer history CKD COPD HTN
Allergies: Penicillin hives Sulfonamide Antibiotics hives hives
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Admitted to hospital with sob upon exertion that started prior to vaccine. Hx COPD, HTN, CKD, hyperlipidemia, bladder cancer in remission. Stated he has been taking Eliquis and Xarelto between renal doctor and cardiologist Dr. Anticipating going home 2/5/21 but then turned blue and stopped breathing under a DNR. COVID test negative. Labs show acute on chronic renal failure with an elevated troponin likely from demand ischemia.


Changed on 5/14/2021

VAERS ID: 1017339 Before After
VAERS Form:2
Age:88.0
Sex:Male
Location:Florida
Vaccinated:2021-01-30
Onset:2021-02-05
Submitted:0000-00-00
Entered:2021-02-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 038K208 / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Cyanosis, Dyspnoea exertional, Laboratory test abnormal, Respiratory arrest, Troponin increased, Acute kidney injury, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-05
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Furosemide Lasix, 20 mg PO daily at 0600 Simvastatin 20 mg Tablet PO daily Amlodipine Norvasc 2.5 mg Tablet PO daily Tamsulosin HCl 0.4 mg Capsle PO daily Dutasteride 0.5 mg Capsule PO daily Metroprolol Tartrate Lopressor 25 mg Tablet PO on
Current Illness: sob with exertion, started just prior to vaccine
Preexisting Conditions: A-fib Bladder cancer history CKD COPD HTN
Allergies: Penicillin hives Sulfonamide Antibiotics hives hives
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Admitted to hospital with sob upon exertion that started prior to vaccine. Hx COPD, HTN, CKD, hyperlipidemia, bladder cancer in remission. Stated he has been taking Eliquis and Xarelto between renal doctor and cardiologist Dr. Anticipating going home 2/5/21 but then turned blue and stopped breathing under a DNR. COVID test negative. Labs show acute on chronic renal failure with an elevated troponin likely from demand ischemia.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1017339&WAYBACKHISTORY=ON

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