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This is VAERS ID 1025497

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1025497
VAERS Form:2
Age:95.0
Sex:Male
Location:Pennsylvania
Vaccinated:2021-01-19
Onset:2021-01-27
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Activated partial thromboplastin time prolonged, Anaemia, Coagulopathy, Disseminated intravascular coagulation, Fibrin D dimer increased, Haematocrit decreased, Haemoglobin decreased, International normalised ratio increased, Platelet count decreased, Prothrombin time prolonged, Tachycardia, White blood cell count increased, Hepatic enzyme increased

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: ASA 81 mg, Atenolol, Lasix, Terozosin, Lovastatin, Amlodipine, Bacitracin oint
Current Illness: None
Preexisting Conditions: Afib, T2DM, Hyperlipidemia, BPH, CKD stage 3, Peripheral Edema, Pulm HTN,
Allergies: None
Diagnostic Lab Data: WBC 17.4 Hgb decreased 10.3 HcT 31.8 Plts 19 LFT all elevated ddimer 2.48 (0-0.5) PT 16.3 PTT 41.4 INR 1.3
CDC 'Split Type':

Write-up: Disseminated Intravascular Coagulation Platelets = 19 Elevated Liver Enzymes. Bleeding coagulopathy Anemia Tachycardia Elevated white blood count


Changed on 5/7/2021

VAERS ID: 1025497 Before After
VAERS Form:2
Age:95.0
Sex:Male
Location:Pennsylvania
Vaccinated:2021-01-19
Onset:2021-01-27
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Activated partial thromboplastin time prolonged, Anaemia, Coagulopathy, Disseminated intravascular coagulation, Fibrin D dimer increased, Haematocrit decreased, Haemoglobin decreased, International normalised ratio increased, Platelet count decreased, Prothrombin time prolonged, Tachycardia, White blood cell count increased, Hepatic enzyme increased

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: ASA 81 mg, Atenolol, Lasix, Terozosin, Lovastatin, Amlodipine, Bacitracin oint
Current Illness: None
Preexisting Conditions: Afib, T2DM, Hyperlipidemia, BPH, CKD stage 3, Peripheral Edema, Pulm HTN,
Allergies: None None
Diagnostic Lab Data: WBC 17.4 Hgb decreased 10.3 HcT 31.8 Plts 19 LFT all elevated ddimer 2.48 (0-0.5) PT 16.3 PTT 41.4 INR 1.3
CDC 'Split Type':

Write-up: Disseminated Intravascular Coagulation Platelets = 19 Elevated Liver Enzymes. Bleeding coagulopathy Anemia Tachycardia Elevated white blood count


Changed on 5/14/2021

VAERS ID: 1025497 Before After
VAERS Form:2
Age:95.0
Sex:Male
Location:Pennsylvania
Vaccinated:2021-01-19
Onset:2021-01-27
Submitted:0000-00-00
Entered:2021-02-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Activated partial thromboplastin time prolonged, Anaemia, Coagulopathy, Disseminated intravascular coagulation, Fibrin D dimer increased, Haematocrit decreased, Haemoglobin decreased, International normalised ratio increased, Platelet count decreased, Prothrombin time prolonged, Tachycardia, White blood cell count increased, Hepatic enzyme increased

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: ASA 81 mg, Atenolol, Lasix, Terozosin, Lovastatin, Amlodipine, Bacitracin oint
Current Illness: None
Preexisting Conditions: Afib, T2DM, Hyperlipidemia, BPH, CKD stage 3, Peripheral Edema, Pulm HTN,
Allergies: None None
Diagnostic Lab Data: WBC 17.4 Hgb decreased 10.3 HcT 31.8 Plts 19 LFT all elevated ddimer 2.48 (0-0.5) PT 16.3 PTT 41.4 INR 1.3
CDC 'Split Type':

Write-up: Disseminated Intravascular Coagulation Platelets = 19 Elevated Liver Enzymes. Bleeding coagulopathy Anemia Tachycardia Elevated white blood count

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