National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts.org
Search Results

This is VAERS ID 1042097

Government Disclaimer on use of this data

History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1042097
VAERS Form:2
Age:86.0
Sex:Male
Location:Minnesota
Vaccinated:2021-02-12
Onset:2021-02-16
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Pulmonary embolism, Pyrexia

Life Threatening? No
Birth Defect? No
Died? No
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: BACTRIM DS, BIOFREEZE, DOCUSATE SOD, CYANOCOBALAMIN 1000 MCG/ML INJ, IPRATROPIUM/ALBUTEROL NEB SOL, TAMSULOSIN, ACETOMINOPHEN 500MG, AMIODARONE 200 MG, ELIQUIS 5 MG, DONEPAZOLE 5mg, fluticasone nasal spray, ibuprofen 800 mg, furosemide 20-
Current Illness: none other than long-standing conditions
Preexisting Conditions: Alzheimer''s late onset, pneumonia, unspecified dementia, weekness, legal blindness, paroxysmal atrial fibrillation, edema unspecified, chronic obstructive pulmonary disease, atherosclerotic heart disease, essential hypertention, GERD, chest pain unspecified, iron deficiency, presence of other cardiac implants and grafts, heart failure
Allergies: mirtazapine, morphine, nitroglycerin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt did not feel ill or had mild symptoms after 2nd dose of vaccine. 4 days later patient developed fever of 101 and not controlled with acetaminophen. Temp increased to 103 and patient taken to ER and then diagnosed with pulmonary embolism. Patient still hospitalized. Not sure if related to vaccine.


Changed on 5/7/2021

VAERS ID: 1042097 Before After
VAERS Form:2
Age:86.0
Sex:Male
Location:Minnesota
Vaccinated:2021-02-12
Onset:2021-02-16
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Pulmonary embolism, Pyrexia

Life Threatening? No
Birth Defect? No
Died? No
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: BACTRIM DS, BIOFREEZE, DOCUSATE SOD, CYANOCOBALAMIN 1000 MCG/ML INJ, IPRATROPIUM/ALBUTEROL NEB SOL, TAMSULOSIN, ACETOMINOPHEN 500MG, AMIODARONE 200 MG, ELIQUIS 5 MG, DONEPAZOLE 5mg, fluticasone nasal spray, ibuprofen 800 mg, furosemide 20-
Current Illness: none other than long-standing conditions
Preexisting Conditions: Alzheimer''s late onset, pneumonia, unspecified dementia, weekness, legal blindness, paroxysmal atrial fibrillation, edema unspecified, chronic obstructive pulmonary disease, atherosclerotic heart disease, essential hypertention, GERD, chest pain unspecified, iron deficiency, presence of other cardiac implants and grafts, heart failure
Allergies: mirtazapine, morphine, nitroglycerin nitroglycerin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt did not feel ill or had mild symptoms after 2nd dose of vaccine. 4 days later patient developed fever of 101 and not controlled with acetaminophen. Temp increased to 103 and patient taken to ER and then diagnosed with pulmonary embolism. Patient still hospitalized. Not sure if related to vaccine.


Changed on 5/21/2021

VAERS ID: 1042097 Before After
VAERS Form:2
Age:86.0
Sex:Male
Location:Minnesota
Vaccinated:2021-02-12
Onset:2021-02-16
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 041L20A / 2 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Pulmonary embolism, Pyrexia

Life Threatening? No
Birth Defect? No
Died? No
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? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: BACTRIM DS, BIOFREEZE, DOCUSATE SOD, CYANOCOBALAMIN 1000 MCG/ML INJ, IPRATROPIUM/ALBUTEROL NEB SOL, TAMSULOSIN, ACETOMINOPHEN 500MG, AMIODARONE 200 MG, ELIQUIS 5 MG, DONEPAZOLE 5mg, fluticasone nasal spray, ibuprofen 800 mg, furosemide 20-
Current Illness: none other than long-standing conditions
Preexisting Conditions: Alzheimer''s late onset, pneumonia, unspecified dementia, weekness, legal blindness, paroxysmal atrial fibrillation, edema unspecified, chronic obstructive pulmonary disease, atherosclerotic heart disease, essential hypertention, GERD, chest pain unspecified, iron deficiency, presence of other cardiac implants and grafts, heart failure
Allergies: mirtazapine, morphine, nitroglycerin nitroglycerin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt did not feel ill or had mild symptoms after 2nd dose of vaccine. 4 days later patient developed fever of 101 and not controlled with acetaminophen. Temp increased to 103 and patient taken to ER and then diagnosed with pulmonary embolism. Patient still hospitalized. Not sure if related to vaccine.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1042097&WAYBACKHISTORY=ON


Copyright © 2022 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166