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This is VAERS ID 1036418

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1036418
VAERS Form:2
Age:85.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-21
Onset:2021-01-25
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood creatinine increased, Blood potassium increased, Blood urea increased, Cardiac arrest, Computerised tomogram abnormal, Death, Generalised oedema, Glomerular filtration rate decreased, Hypotension, Oedema, Platelet count decreased, Pleural effusion, Pneumonia, Pulmonary oedema, Pulse absent, Resuscitation, Syncope, General physical health deterioration, Central venous catheterisation, Troponin increased, Acute kidney injury, Lung opacity, Abdominal wall oedema, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Meds as of 1/20/21: Aspirin 81 daily; Carvedilol changed to Metoprolol XL; CoQ10 daily; digoxin 3xweek; fluticasone propionate daily; furosemide 80 mg twice daily; Iron 325mg daily; L-Carnitine daily; lisinopril 2.5 daily; Metamucil plus; M
Current Illness: Outpatient hospital admit 12/20-12/21 with CHF exacerbation; BNP 2510, platelet count 99; total bili 2.3; BUN 26, Cr 1.42 and GFR 47. Repeat labs 12/31/20 BUN 28; Cr 1.52; GFR 44; 1/2/21 total bili 2.6; platelet count 89. PCP visit 1/7 noted pitting edema BLE and wife stated more confused lately diagnosis hypertension, elevated bilirubin, thrombocytopenia and shortness of breath, CXR 1/7 cardiomegaly, central vascular congestion, tiny bilateral pleural effusions and mucous plugging. Cardiologist visit 1/20/2021 with med changes.
Preexisting Conditions: Anemia, CABG, apnea; CHF; dysrhythmia; pacemaker/defibrillator; cardiomegaly; heart disease; aortic valve replacement; former smoker; ischemic cardiomyopathy; perivalvular leak of prosthetic heart valve
Allergies: No Known allergies
Diagnostic Lab Data: 1/25/21 Rapid COVID negative; Troponin 0.87; platelet count 92; BUN 50, Cr 2.96; GFR 20; SGOT 132; SGPT 102; Potassium 5.5 CT revealed ground glass opacities representing pneumonia versus pulmonary edema; diffuse body wall edema and pleural effusions. Pacemaker/defibrillator interrogated with no shocks or other events noted.
CDC 'Split Type':

Write-up: ER visit 1/25/21 patient walked into a prompt care and collapsed, witnessed and pulseless CPR with ROSC after 6-7mins, no shock no meds. Awake and speaking upon arrival to ER. 2 plus pitting edema ble ER diagnosis Anasarca, cardiac arrest, hypotension, elevated troponin I levels, Acute kidney injury and syncope. ER notes reveal a syncopal episode in the shower prior to collapse at prompt care. Central line placed and plan to ship to another facility, patient continued to decline despite dopamine and dobutamine expired in ER prior to transfer.


Changed on 5/7/2021

VAERS ID: 1036418 Before After
VAERS Form:2
Age:85.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-21
Onset:2021-01-25
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood creatinine increased, Blood potassium increased, Blood urea increased, Cardiac arrest, Computerised tomogram abnormal, Death, Generalised oedema, Glomerular filtration rate decreased, Hypotension, Oedema, Platelet count decreased, Pleural effusion, Pneumonia, Pulmonary oedema, Pulse absent, Resuscitation, Syncope, General physical health deterioration, Central venous catheterisation, Troponin increased, Acute kidney injury, Lung opacity, Abdominal wall oedema, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Meds as of 1/20/21: Aspirin 81 daily; Carvedilol changed to Metoprolol XL; CoQ10 daily; digoxin 3xweek; fluticasone propionate daily; furosemide 80 mg twice daily; Iron 325mg daily; L-Carnitine daily; lisinopril 2.5 daily; Metamucil plus; M
Current Illness: Outpatient hospital admit 12/20-12/21 with CHF exacerbation; BNP 2510, platelet count 99; total bili 2.3; BUN 26, Cr 1.42 and GFR 47. Repeat labs 12/31/20 BUN 28; Cr 1.52; GFR 44; 1/2/21 total bili 2.6; platelet count 89. PCP visit 1/7 noted pitting edema BLE and wife stated more confused lately diagnosis hypertension, elevated bilirubin, thrombocytopenia and shortness of breath, CXR 1/7 cardiomegaly, central vascular congestion, tiny bilateral pleural effusions and mucous plugging. Cardiologist visit 1/20/2021 with med changes.
Preexisting Conditions: Anemia, CABG, apnea; CHF; dysrhythmia; pacemaker/defibrillator; cardiomegaly; heart disease; aortic valve replacement; former smoker; ischemic cardiomyopathy; perivalvular leak of prosthetic heart valve
Allergies: No Known allergies allergies
Diagnostic Lab Data: 1/25/21 Rapid COVID negative; Troponin 0.87; platelet count 92; BUN 50, Cr 2.96; GFR 20; SGOT 132; SGPT 102; Potassium 5.5 CT revealed ground glass opacities representing pneumonia versus pulmonary edema; diffuse body wall edema and pleural effusions. Pacemaker/defibrillator interrogated with no shocks or other events noted.
CDC 'Split Type':

Write-up: ER visit 1/25/21 patient walked into a prompt care and collapsed, witnessed and pulseless CPR with ROSC after 6-7mins, no shock no meds. Awake and speaking upon arrival to ER. 2 plus pitting edema ble ER diagnosis Anasarca, cardiac arrest, hypotension, elevated troponin I levels, Acute kidney injury and syncope. ER notes reveal a syncopal episode in the shower prior to collapse at prompt care. Central line placed and plan to ship to another facility, patient continued to decline despite dopamine and dobutamine expired in ER prior to transfer.


Changed on 5/14/2021

VAERS ID: 1036418 Before After
VAERS Form:2
Age:85.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-21
Onset:2021-01-25
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood creatinine increased, Blood potassium increased, Blood urea increased, Cardiac arrest, Computerised tomogram abnormal, Death, Generalised oedema, Glomerular filtration rate decreased, Hypotension, Oedema, Platelet count decreased, Pleural effusion, Pneumonia, Pulmonary oedema, Pulse absent, Resuscitation, Syncope, General physical health deterioration, Central venous catheterisation, Troponin increased, Acute kidney injury, Lung opacity, Abdominal wall oedema, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-25
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Meds as of 1/20/21: Aspirin 81 daily; Carvedilol changed to Metoprolol XL; CoQ10 daily; digoxin 3xweek; fluticasone propionate daily; furosemide 80 mg twice daily; Iron 325mg daily; L-Carnitine daily; lisinopril 2.5 daily; Metamucil plus; M
Current Illness: Outpatient hospital admit 12/20-12/21 with CHF exacerbation; BNP 2510, platelet count 99; total bili 2.3; BUN 26, Cr 1.42 and GFR 47. Repeat labs 12/31/20 BUN 28; Cr 1.52; GFR 44; 1/2/21 total bili 2.6; platelet count 89. PCP visit 1/7 noted pitting edema BLE and wife stated more confused lately diagnosis hypertension, elevated bilirubin, thrombocytopenia and shortness of breath, CXR 1/7 cardiomegaly, central vascular congestion, tiny bilateral pleural effusions and mucous plugging. Cardiologist visit 1/20/2021 with med changes.
Preexisting Conditions: Anemia, CABG, apnea; CHF; dysrhythmia; pacemaker/defibrillator; cardiomegaly; heart disease; aortic valve replacement; former smoker; ischemic cardiomyopathy; perivalvular leak of prosthetic heart valve
Allergies: No Known allergies allergies
Diagnostic Lab Data: 1/25/21 Rapid COVID negative; Troponin 0.87; platelet count 92; BUN 50, Cr 2.96; GFR 20; SGOT 132; SGPT 102; Potassium 5.5 CT revealed ground glass opacities representing pneumonia versus pulmonary edema; diffuse body wall edema and pleural effusions. Pacemaker/defibrillator interrogated with no shocks or other events noted.
CDC 'Split Type':

Write-up: ER visit 1/25/21 patient walked into a prompt care and collapsed, witnessed and pulseless CPR with ROSC after 6-7mins, no shock no meds. Awake and speaking upon arrival to ER. 2 plus pitting edema ble ER diagnosis Anasarca, cardiac arrest, hypotension, elevated troponin I levels, Acute kidney injury and syncope. ER notes reveal a syncopal episode in the shower prior to collapse at prompt care. Central line placed and plan to ship to another facility, patient continued to decline despite dopamine and dobutamine expired in ER prior to transfer.

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