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This is VAERS ID 1024627

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1024627
VAERS Form:2
Age:77.0
Sex:Male
Location:Louisiana
Vaccinated:2021-02-02
Onset:2021-02-05
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNSURE / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Atrial fibrillation, Cough, Death, Disseminated intravascular coagulation, Dyspnoea, Feeling abnormal, Hypertension, Pyrexia, COVID-19

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-02-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: nothing
Current Illness: none
Preexisting Conditions: DVT - popliteal in 1995 hypertension hyperlipidemia
Allergies: nkda
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: covid shot 2/2; feel bad 2/5; covid positive diagnosis - 2/8 s/s cough, fever, shortness of breath , hypertension, afib (in er) - admitted went into DIC per intensivist 2/11 patient died


Changed on 5/7/2021

VAERS ID: 1024627 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Louisiana
Vaccinated:2021-02-02
Onset:2021-02-05
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNSURE / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Atrial fibrillation, Cough, Death, Disseminated intravascular coagulation, Dyspnoea, Feeling abnormal, Hypertension, Pyrexia, COVID-19

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-02-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: nothing
Current Illness: none
Preexisting Conditions: DVT - popliteal in 1995 hypertension hyperlipidemia
Allergies: nkda nkda
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: covid shot 2/2; feel bad 2/5; covid positive diagnosis - 2/8 s/s cough, fever, shortness of breath , hypertension, afib (in er) - admitted went into DIC per intensivist 2/11 patient died


Changed on 5/14/2021

VAERS ID: 1024627 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Louisiana
Vaccinated:2021-02-02
Onset:2021-02-05
Submitted:0000-00-00
Entered:2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA UNSURE / 1 LA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Atrial fibrillation, Cough, Death, Disseminated intravascular coagulation, Dyspnoea, Feeling abnormal, Hypertension, Pyrexia, COVID-19

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-02-11
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: nothing
Current Illness: none
Preexisting Conditions: DVT - popliteal in 1995 hypertension hyperlipidemia
Allergies: nkda nkda
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: covid shot 2/2; feel bad 2/5; covid positive diagnosis - 2/8 s/s cough, fever, shortness of breath , hypertension, afib (in er) - admitted went into DIC per intensivist 2/11 patient died

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1024627&WAYBACKHISTORY=ON


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