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This is VAERS ID 1030787

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1030787
VAERS Form:2
Age:67.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-04
Onset:2021-02-06
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / -

Administered by: Private      Purchased by: ??
Symptoms: Acute myocardial infarction, Atrioventricular block second degree, Bradycardia, Cardiac arrest, Cardiac pacemaker insertion, Chest discomfort, Death, Electrocardiogram ST segment elevation, Nausea, Resuscitation, Retching, Unresponsive to stimuli, Ventricular fibrillation, Ventricular hypokinesia, Pulseless electrical activity, Echocardiogram abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: Allopurinol 300mg PO daily, Simvastatin 10mg qhs
Current Illness:
Preexisting Conditions: tubolovillous adenoma, chronic kidney disease, gout, hyperlipidemia, hx of kidney stone.
Allergies: No known drug allergies
Diagnostic Lab Data: EKG (2/12/21) - Sinus rhythm with 2:1 conduction block and anterior ST elevation ECHO bedside (2/12/21) - 1.LVEF< 10% with global diffuse severe hypokinesis - LV stand still. ?
CDC 'Split Type':

Write-up: Pt admitted from home with intermittent nausea, dry heaving, and central chest pressure which self resolve in 2 minutes since 2/6/21. Called 911 on 2/12/21 due to sustained episode that did not resolve. EMS treated with aspirin and nitroglycerin prior to arrival to ED. In ED patient became unresponsive and went into full cardiac arrest -CPR and ACLS care initiated. STEMI with AV conduction block. 2nd degree a-v block type II - significant bradycardia - temoprary pacemaker placed - Vfib -PEA. Time of death 0955 on 2/12/21 Patient recieved first dose of Moderna Covid vaccine on 2/4/21


Changed on 4/23/2021

VAERS ID: 1030787 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-04
Onset:2021-02-06
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / -

Administered by: Private      Purchased by: ??
Symptoms: Acute myocardial infarction, Atrioventricular block second degree, Bradycardia, Cardiac arrest, Cardiac pacemaker insertion, Chest discomfort, Death, Electrocardiogram ST segment elevation, Nausea, Resuscitation, Retching, Unresponsive to stimuli, Ventricular fibrillation, Ventricular hypokinesia, Pulseless electrical activity, Echocardiogram abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: Allopurinol 300mg PO daily, Simvastatin 10mg qhs
Current Illness:
Preexisting Conditions: tubolovillous adenoma, chronic kidney disease, gout, hyperlipidemia, hx of kidney stone.
Allergies: No known drug allergies
Diagnostic Lab Data: EKG (2/12/21) - Sinus rhythm with 2:1 conduction block and anterior ST elevation ECHO bedside (2/12/21) - 1.LVEF< 10% with global diffuse severe hypokinesis - LV stand still. ?
CDC 'Split Type':

Write-up: Pt admitted from home with intermittent nausea, dry heaving, and central chest pressure which self resolve in 2 minutes since 2/6/21. Called 911 on 2/12/21 due to sustained episode that did not resolve. EMS treated with aspirin and nitroglycerin prior to arrival to ED. In ED patient became unresponsive and went into full cardiac arrest -CPR and ACLS care initiated. STEMI with AV conduction block. 2nd degree a-v block type II - significant bradycardia - temoprary pacemaker placed - Vfib -PEA. Time of death 0955 on 2/12/21 Patient recieved first dose of Moderna Covid vaccine on 2/4/21


Changed on 5/7/2021

VAERS ID: 1030787 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-04
Onset:2021-02-06
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / -

Administered by: Private      Purchased by: ??
Symptoms: Acute myocardial infarction, Atrioventricular block second degree, Bradycardia, Cardiac arrest, Cardiac pacemaker insertion, Chest discomfort, Death, Electrocardiogram ST segment elevation, Nausea, Resuscitation, Retching, Unresponsive to stimuli, Ventricular fibrillation, Ventricular hypokinesia, Pulseless electrical activity, Echocardiogram abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: Allopurinol 300mg PO daily, Simvastatin 10mg qhs
Current Illness:
Preexisting Conditions: tubolovillous adenoma, chronic kidney disease, gout, hyperlipidemia, hx of kidney stone.
Allergies: No known drug allergies allergies
Diagnostic Lab Data: EKG (2/12/21) - Sinus rhythm with 2:1 conduction block and anterior ST elevation ECHO bedside (2/12/21) - 1.LVEF< 10% with global diffuse severe hypokinesis - LV stand still.
CDC 'Split Type':

Write-up: Pt admitted from home with intermittent nausea, dry heaving, and central chest pressure which self resolve in 2 minutes since 2/6/21. Called 911 on 2/12/21 due to sustained episode that did not resolve. EMS treated with aspirin and nitroglycerin prior to arrival to ED. In ED patient became unresponsive and went into full cardiac arrest -CPR and ACLS care initiated. STEMI with AV conduction block. 2nd degree a-v block type II - significant bradycardia - temoprary pacemaker placed - Vfib -PEA. Time of death 0955 on 2/12/21 Patient recieved first dose of Moderna Covid vaccine on 2/4/21


Changed on 5/14/2021

VAERS ID: 1030787 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-04
Onset:2021-02-06
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010M20A / 1 - / -

Administered by: Private      Purchased by: ??
Symptoms: Acute myocardial infarction, Atrioventricular block second degree, Bradycardia, Cardiac arrest, Cardiac pacemaker insertion, Chest discomfort, Death, Electrocardiogram ST segment elevation, Nausea, Resuscitation, Retching, Unresponsive to stimuli, Ventricular fibrillation, Ventricular hypokinesia, Pulseless electrical activity, Echocardiogram abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:0000-00-00
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: Allopurinol 300mg PO daily, Simvastatin 10mg qhs
Current Illness:
Preexisting Conditions: tubolovillous adenoma, chronic kidney disease, gout, hyperlipidemia, hx of kidney stone.
Allergies: No known drug allergies allergies
Diagnostic Lab Data: EKG (2/12/21) - Sinus rhythm with 2:1 conduction block and anterior ST elevation ECHO bedside (2/12/21) - 1.LVEF< 10% with global diffuse severe hypokinesis - LV stand still.
CDC 'Split Type':

Write-up: Pt admitted from home with intermittent nausea, dry heaving, and central chest pressure which self resolve in 2 minutes since 2/6/21. Called 911 on 2/12/21 due to sustained episode that did not resolve. EMS treated with aspirin and nitroglycerin prior to arrival to ED. In ED patient became unresponsive and went into full cardiac arrest -CPR and ACLS care initiated. STEMI with AV conduction block. 2nd degree a-v block type II - significant bradycardia - temoprary pacemaker placed - Vfib -PEA. Time of death 0955 on 2/12/21 Patient recieved first dose of Moderna Covid vaccine on 2/4/21

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