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This is VAERS ID 1019577

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1019577
VAERS Form:2
Age:82.0
Sex:Male
Location:Delaware
Vaccinated:2021-02-02
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Dyspnoea, Electrocardiogram normal, Fatigue, Pulmonary embolism, Pyrexia, Urinary tract infection, Vomiting, White blood cell count increased, Laboratory test, Angiogram, Urine analysis abnormal, SARS-CoV-2 test negative

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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: escitalopram, fludrocortisone, gabapentin, Klor-con, mestinon, northera, pravastatin, valacyclovir, velcade, zofran, centrum silver, vitamin B12, metamucil, caltrate plus D
Current Illness: no acute illness; undergoing treatment for multiple myeloma
Preexisting Conditions: multiple myeloma, afib, CKD, sleep apnea, autonomic dysfunction / hypotension, urinary retention (requiring straight cath multiple times daily), hyperlipidemia
Allergies: none
Diagnostic Lab Data: CTA chest - showing small PE 2/9/21 UA - multiple white blood cells and bacteria (culture pending) 2/9/21 CBC with WBC count slightly elevated at 11.3 - 2/9/21 COVID PCR test negative - 2/9/21 Other labs and EKG unremarkable / stable
CDC 'Split Type':

Write-up: Pt awoke on 2/8 feeling tired and weak. On 2/9 patient developed fever to 102 and shortness of breath and vomiting. Was seen in ER and admitted for presumed UTI as well as small PE.


Changed on 5/7/2021

VAERS ID: 1019577 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Delaware
Vaccinated:2021-02-02
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Dyspnoea, Electrocardiogram normal, Fatigue, Pulmonary embolism, Pyrexia, Urinary tract infection, Vomiting, White blood cell count increased, Laboratory test, Angiogram, Urine analysis abnormal, SARS-CoV-2 test negative

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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: escitalopram, fludrocortisone, gabapentin, Klor-con, mestinon, northera, pravastatin, valacyclovir, velcade, zofran, centrum silver, vitamin B12, metamucil, caltrate plus D
Current Illness: no acute illness; undergoing treatment for multiple myeloma
Preexisting Conditions: multiple myeloma, afib, CKD, sleep apnea, autonomic dysfunction / hypotension, urinary retention (requiring straight cath multiple times daily), hyperlipidemia
Allergies: none none
Diagnostic Lab Data: CTA chest - showing small PE 2/9/21 UA - multiple white blood cells and bacteria (culture pending) 2/9/21 CBC with WBC count slightly elevated at 11.3 - 2/9/21 COVID PCR test negative - 2/9/21 Other labs and EKG unremarkable / stable
CDC 'Split Type':

Write-up: Pt awoke on 2/8 feeling tired and weak. On 2/9 patient developed fever to 102 and shortness of breath and vomiting. Was seen in ER and admitted for presumed UTI as well as small PE.


Changed on 5/21/2021

VAERS ID: 1019577 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Delaware
Vaccinated:2021-02-02
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Dyspnoea, Electrocardiogram normal, Fatigue, Pulmonary embolism, Pyrexia, Urinary tract infection, Vomiting, White blood cell count increased, Laboratory test, Angiogram, Urine analysis abnormal, SARS-CoV-2 test negative

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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: escitalopram, fludrocortisone, gabapentin, Klor-con, mestinon, northera, pravastatin, valacyclovir, velcade, zofran, centrum silver, vitamin B12, metamucil, caltrate plus D
Current Illness: no acute illness; undergoing treatment for multiple myeloma
Preexisting Conditions: multiple myeloma, afib, CKD, sleep apnea, autonomic dysfunction / hypotension, urinary retention (requiring straight cath multiple times daily), hyperlipidemia
Allergies: none none
Diagnostic Lab Data: CTA chest - showing small PE 2/9/21 UA - multiple white blood cells and bacteria (culture pending) 2/9/21 CBC with WBC count slightly elevated at 11.3 - 2/9/21 COVID PCR test negative - 2/9/21 Other labs and EKG unremarkable / stable
CDC 'Split Type':

Write-up: Pt awoke on 2/8 feeling tired and weak. On 2/9 patient developed fever to 102 and shortness of breath and vomiting. Was seen in ER and admitted for presumed UTI as well as small PE.

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