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This is VAERS ID 1022440

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1022440
VAERS Form:2
Age:69.0
Sex:Male
Location:Florida
Vaccinated:2021-01-23
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Acute myocardial infarction, Chest pain, Death, Dyspnoea, Pericarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-09
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: None
Current Illness: None
Preexisting Conditions: HTN, hyperlipidemia, pericarditis (diagnosed in 2014)
Allergies: None
Diagnostic Lab Data: None reported
CDC 'Split Type':

Write-up: The decedent experienced severe chest pain and dyspnea approximately nine days following the first series of the vaccine. He reported to family members that he was having a "severe reaction" to the vaccine and believed it was acute pericarditis due to the same symptoms he experienced prior. He reported that on 2/1/21 around 0300 hours, the symptoms were the most severe and he was going to seek medical attention, but did not. He waited till the convenient store opened and purchased OTC Tylenol for relief of symptoms. He continued to have dyspnea and chest pain up until 2/9/21, when he called 911 complaining of chest pain and was found to have a STEMI; subsequently died at Hospital in the ER.


Changed on 5/7/2021

VAERS ID: 1022440 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:Florida
Vaccinated:2021-01-23
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Acute myocardial infarction, Chest pain, Death, Dyspnoea, Pericarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-09
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: None
Current Illness: None
Preexisting Conditions: HTN, hyperlipidemia, pericarditis (diagnosed in 2014)
Allergies: None None
Diagnostic Lab Data: None reported
CDC 'Split Type':

Write-up: The decedent experienced severe chest pain and dyspnea approximately nine days following the first series of the vaccine. He reported to family members that he was having a "severe reaction" to the vaccine and believed it was acute pericarditis due to the same symptoms he experienced prior. He reported that on 2/1/21 around 0300 hours, the symptoms were the most severe and he was going to seek medical attention, but did not. He waited till the convenient store opened and purchased OTC Tylenol for relief of symptoms. He continued to have dyspnea and chest pain up until 2/9/21, when he called 911 complaining of chest pain and was found to have a STEMI; subsequently died at Hospital in the ER.


Changed on 5/14/2021

VAERS ID: 1022440 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:Florida
Vaccinated:2021-01-23
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Acute myocardial infarction, Chest pain, Death, Dyspnoea, Pericarditis

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-09
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: None
Current Illness: None
Preexisting Conditions: HTN, hyperlipidemia, pericarditis (diagnosed in 2014)
Allergies: None None
Diagnostic Lab Data: None reported
CDC 'Split Type':

Write-up: The decedent experienced severe chest pain and dyspnea approximately nine days following the first series of the vaccine. He reported to family members that he was having a "severe reaction" to the vaccine and believed it was acute pericarditis due to the same symptoms he experienced prior. He reported that on 2/1/21 around 0300 hours, the symptoms were the most severe and he was going to seek medical attention, but did not. He waited till the convenient store opened and purchased OTC Tylenol for relief of symptoms. He continued to have dyspnea and chest pain up until 2/9/21, when he called 911 complaining of chest pain and was found to have a STEMI; subsequently died at Hospital in the ER.

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