National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1030323

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1030323
VAERS Form:2
Age:66.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-02-03
Onset:2021-02-05
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / UNK - / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood potassium normal, Blood sodium normal, Carbon dioxide normal, Cardio-respiratory arrest, Death, Fall, Haemoglobin decreased, Resuscitation, Unresponsive to stimuli, Laboratory test

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? No
Previous Vaccinations:
Other Medications: Albuterol Alirocumab Asprin Atrorvastatin Calcium Budesonide-Formoterol Fumarate Calcitriol Calcium Acetate Carvedilol Clopidogrel Bisulfate Erogcalciferol Ezetimibe Fluticasone-Salmetrol Lasix Glucagon Hydralazine Insulin Ipratropium inhal
Current Illness: Asymptomatic COVID Hospital for Polymosis January
Preexisting Conditions: ESRD Diabetes Type 2 Heart disease CHF CAD CABG
Allergies: Niacin
Diagnostic Lab Data: 2/3 labs potassium 4.5, sodium 137, CO2 29, hgb 9.7
CDC 'Split Type':

Write-up: Patient had COVID vaccination on 2/3 with no adverse s/s before leaving unit. Upon coming to treatment Friday 2/5 he reported to the RN that he had fallen on thursday 2/4 due to "getting up fast" did not hit head or hurt anything per RN discussion. Began treatment without difficulty. About 3/4 way through treatment was talking with staff and became unresponsive - code was called and pt expired after 30 minute resuscitation efforts.


Changed on 5/7/2021

VAERS ID: 1030323 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-02-03
Onset:2021-02-05
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / UNK - / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood potassium normal, Blood sodium normal, Carbon dioxide normal, Cardio-respiratory arrest, Death, Fall, Haemoglobin decreased, Resuscitation, Unresponsive to stimuli, Laboratory test

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? No
Previous Vaccinations:
Other Medications: Albuterol Alirocumab Asprin Atrorvastatin Calcium Budesonide-Formoterol Fumarate Calcitriol Calcium Acetate Carvedilol Clopidogrel Bisulfate Erogcalciferol Ezetimibe Fluticasone-Salmetrol Lasix Glucagon Hydralazine Insulin Ipratropium inhal
Current Illness: Asymptomatic COVID Hospital for Polymosis January
Preexisting Conditions: ESRD Diabetes Type 2 Heart disease CHF CAD CABG
Allergies: Niacin Niacin
Diagnostic Lab Data: 2/3 labs potassium 4.5, sodium 137, CO2 29, hgb 9.7
CDC 'Split Type':

Write-up: Patient had COVID vaccination on 2/3 with no adverse s/s before leaving unit. Upon coming to treatment Friday 2/5 he reported to the RN that he had fallen on thursday 2/4 due to "getting up fast" did not hit head or hurt anything per RN discussion. Began treatment without difficulty. About 3/4 way through treatment was talking with staff and became unresponsive - code was called and pt expired after 30 minute resuscitation efforts.


Changed on 5/14/2021

VAERS ID: 1030323 Before After
VAERS Form:2
Age:66.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-02-03
Onset:2021-02-05
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / UNK - / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood potassium normal, Blood sodium normal, Carbon dioxide normal, Cardio-respiratory arrest, Death, Fall, Haemoglobin decreased, Resuscitation, Unresponsive to stimuli, Laboratory test

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? No
Previous Vaccinations:
Other Medications: Albuterol Alirocumab Asprin Atrorvastatin Calcium Budesonide-Formoterol Fumarate Calcitriol Calcium Acetate Carvedilol Clopidogrel Bisulfate Erogcalciferol Ezetimibe Fluticasone-Salmetrol Lasix Glucagon Hydralazine Insulin Ipratropium inhal
Current Illness: Asymptomatic COVID Hospital for Polymosis January
Preexisting Conditions: ESRD Diabetes Type 2 Heart disease CHF CAD CABG
Allergies: Niacin Niacin
Diagnostic Lab Data: 2/3 labs potassium 4.5, sodium 137, CO2 29, hgb 9.7
CDC 'Split Type':

Write-up: Patient had COVID vaccination on 2/3 with no adverse s/s before leaving unit. Upon coming to treatment Friday 2/5 he reported to the RN that he had fallen on thursday 2/4 due to "getting up fast" did not hit head or hurt anything per RN discussion. Began treatment without difficulty. About 3/4 way through treatment was talking with staff and became unresponsive - code was called and pt expired after 30 minute resuscitation efforts.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1030323&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166