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This is VAERS ID 1036098

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1036098
VAERS Form:2
Age:77.0
Sex:Male
Location:Arkansas
Vaccinated:2021-01-31
Onset:2021-02-07
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, International normalised ratio increased, Urinary tract infection, Haemorrhage, Urine analysis abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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: coumadin 5 mg, clopidogrel 75 mg, atorvastatin 20 mg, citalopram 10 mg, levothyroxine 75 mcg, lisinopril-hctz 20-12.5 mg, melatonin 5 mg
Current Illness:
Preexisting Conditions: Hypothyroidism; History of coronary artery stent placement; Essential hypertension; Current use of long term anticoagulation
Allergies: NKDA
Diagnostic Lab Data: INR test on 2/10/2021- results INR 12 Urinalysis 2/10/2021- results- abnormal
CDC 'Split Type':

Write-up: Patient received the vaccine on 1/31/2021. Patient complained of bleeding 2/7/2021. Went to clinic where labs were conducted. Patient had an INR of 12. Previous INR results were normal prior to vaccination. Patient was also diagnosed with UTI and given antibiotics. Patient was encouraged to go to ER. Patient died on 2/12/2021.


Changed on 5/7/2021

VAERS ID: 1036098 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Arkansas
Vaccinated:2021-01-31
Onset:2021-02-07
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, International normalised ratio increased, Urinary tract infection, Haemorrhage, Urine analysis abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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: coumadin 5 mg, clopidogrel 75 mg, atorvastatin 20 mg, citalopram 10 mg, levothyroxine 75 mcg, lisinopril-hctz 20-12.5 mg, melatonin 5 mg
Current Illness:
Preexisting Conditions: Hypothyroidism; History of coronary artery stent placement; Essential hypertension; Current use of long term anticoagulation
Allergies: NKDA NKDA
Diagnostic Lab Data: INR test on 2/10/2021- results INR 12 Urinalysis 2/10/2021- results- abnormal
CDC 'Split Type':

Write-up: Patient received the vaccine on 1/31/2021. Patient complained of bleeding 2/7/2021. Went to clinic where labs were conducted. Patient had an INR of 12. Previous INR results were normal prior to vaccination. Patient was also diagnosed with UTI and given antibiotics. Patient was encouraged to go to ER. Patient died on 2/12/2021.


Changed on 5/14/2021

VAERS ID: 1036098 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Arkansas
Vaccinated:2021-01-31
Onset:2021-02-07
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, International normalised ratio increased, Urinary tract infection, Haemorrhage, Urine analysis abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-12
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: coumadin 5 mg, clopidogrel 75 mg, atorvastatin 20 mg, citalopram 10 mg, levothyroxine 75 mcg, lisinopril-hctz 20-12.5 mg, melatonin 5 mg
Current Illness:
Preexisting Conditions: Hypothyroidism; History of coronary artery stent placement; Essential hypertension; Current use of long term anticoagulation
Allergies: NKDA NKDA
Diagnostic Lab Data: INR test on 2/10/2021- results INR 12 Urinalysis 2/10/2021- results- abnormal
CDC 'Split Type':

Write-up: Patient received the vaccine on 1/31/2021. Patient complained of bleeding 2/7/2021. Went to clinic where labs were conducted. Patient had an INR of 12. Previous INR results were normal prior to vaccination. Patient was also diagnosed with UTI and given antibiotics. Patient was encouraged to go to ER. Patient died on 2/12/2021.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1036098&WAYBACKHISTORY=ON

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