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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1030468



Case Details

VAERS ID: 1030468 (history)  
Form: Version 2.0  
Age: 76.0  
Sex: Male  
Location: Nebraska  
Vaccinated:2021-02-11
Onset:2021-02-12
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 024M20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute kidney injury, Asthenia, Blood creatinine increased, Blood potassium increased, Brain natriuretic peptide increased, C-reactive protein increased, Death, Hyperkalaemia, Hypotension, Hypoxia, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Cardiac failure (broad), Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-13
   Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril, Flomax, Sotalol, simvastatin, Xarelto, Requip, Omeprazole, symbicort, Albuterol Aerosol, Furosemide.
Current Illness: ACUTE KIDNEY FAILURE, QUESTION SEPSIS, CHF, ATRIAL FIBRILLATION, COPD, GERD, RESTLESS LEG SYNDROME, HISTORY OF PROSTATE CANCER, HYPERTENSION, CURENT TOBACCO USAGE
Preexisting Conditions: COPD, CHF, ATRIAL FIBRILLATION, GERD, RESTLESS LEG, HISTORY OF PROSTATE CANCER, HYPERTENSION
Allergies: none
Diagnostic Lab Data: potassium 7.2, creatinine 4.3, CRP 50. BNP 3230. WBC 10,200.
CDC Split Type:

Write-up: Pt presents to ER with increased weakness, hypoxia, history of COPD, but not oxygen dependent., hypotension. Acute Kidney failure noted in labs, not previously diagnosed , new hyperkalemia. BP 73/39, HR 67. dopamine initiated, and switched to Levophed. Oxygen Sat 86%, requiring 10 L O2. Transferred from this critical access hospital to another Hospital. Expires later 2-13-2021


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