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This is VAERS ID 1050137

History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1050137
VAERS Form:2
Age:89.0
Sex:Male
Location:Louisiana
Vaccinated:2021-02-21
Onset:2021-02-22
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 2 UN / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Back pain, Blood chloride decreased, Blood creatinine increased, Blood glucose increased, Blood lactic acid, Blood potassium increased, Blood sodium normal, Blood urea increased, C-reactive protein increased, C-reactive protein normal, Chest X-ray abnormal, Death, Electrocardiogram, Electrocardiogram abnormal, Haematocrit increased, Haemoglobin increased, Headache, Hyperglycaemia, Hypotension, Petechiae, White blood cell count increased, Agonal death struggle, Contusion, Brain natriuretic peptide increased, Pacemaker generated rhythm, Troponin, Lung opacity

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-23
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: Entresto, Metoprolol, Spironolactone, Vit D, Lasix, Flomax, Digoxin, Eliquis, Tradjenta, ASA, Novolog Flex pen, Levothyroxine, Vit B12, Lipitor, Aricept, Temazepam, Lorazepam, Glucose prn.
Current Illness: Fall on 2/15/21 pm resulting in skin tear requiring dressing. Pt Seen on 2/16 for skin tear repair secondary to fall the pm prior. Vital signs WNL. Pt returned on 2/20/21 for dressing change. Vital signs WNL. Pt received second Moderna Vaccination on 2/21/21 at 1:00 pm at Pharmacy. Pt present on 2/22/21 to ER via ambulance at 1940. Upon presentation C/C hypotension Post COVID vaccine. Nurse notes Home Health nurse sent secondary to hypotension and hyperglycemia. Pt states back ached and was holding his head. Nurse noted pt had random petechiae over body and bruising to abdomen following injections received during recent hospitalization. (unknown hospitalization)
Preexisting Conditions: Hypertension, MI, CHF, DM, CRF, Thyroid, High Cholesterol, Prostate
Allergies: Shrimp, Red Man Syndrome, Cleocin, Clindamycin
Diagnostic Lab Data: 2/22/21: CBC WBC 11.74, H/H: 8.6/26.8. Glu $g625mg/dl, BUN 70, Creatnine $g4.10, Sodium <114, Potassium $g6.8, Cl 81, Troponin 0.583, CRP 1.5 BNP 26900, Lactate 8.4 CXR: Subtle inter stitial opacities could represent atelectasis, superimposed mild bronchitis or edema suspected.EKG: Ventricular Paced rhythm. Unsure if death applicable as adverse event secondary to vaccination. Physician noted Vascular Collapse post covid vaccine.
CDC 'Split Type':

Write-up: Pt received second Moderna Vaccination on 2/21/21 at 1:00 pm at Pharmacy. Pt present on 2/22/21 to ER via ambulance at 1940. Upon presentation C/C hypotension Post COVID vaccine. Nurse notes states that Home Health nurse sent patient to ER secondary to hypotension and hyperglycemia. Pt states back ached and was holding his head. Nurse noted pt had random petechiae over body and bruising to abdomen following injections received during recent hospitalization. (unknown hospitalization). Patient was treated with IVF bolus in addition to initiating Dopamine for hypotension, patient became agonal and daughter at bedside presented Adv. Directive, pt was DNR. Pt pronounced time of death was 2110pm. (Pt only reported a sore shoulder secondary to vaccine).


Changed on 5/7/2021

VAERS ID: 1050137 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:Louisiana
Vaccinated:2021-02-21
Onset:2021-02-22
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 2 UN / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Back pain, Blood chloride decreased, Blood creatinine increased, Blood glucose increased, Blood lactic acid, Blood potassium increased, Blood sodium normal, Blood urea increased, C-reactive protein increased, C-reactive protein normal, Chest X-ray abnormal, Death, Electrocardiogram, Electrocardiogram abnormal, Haematocrit increased, Haemoglobin increased, Headache, Hyperglycaemia, Hypotension, Petechiae, White blood cell count increased, Agonal death struggle, Contusion, Brain natriuretic peptide increased, Pacemaker generated rhythm, Troponin, Lung opacity

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-23
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: Entresto, Metoprolol, Spironolactone, Vit D, Lasix, Flomax, Digoxin, Eliquis, Tradjenta, ASA, Novolog Flex pen, Levothyroxine, Vit B12, Lipitor, Aricept, Temazepam, Lorazepam, Glucose prn.
Current Illness: Fall on 2/15/21 pm resulting in skin tear requiring dressing. Pt Seen on 2/16 for skin tear repair secondary to fall the pm prior. Vital signs WNL. Pt returned on 2/20/21 for dressing change. Vital signs WNL. Pt received second Moderna Vaccination on 2/21/21 at 1:00 pm at Pharmacy. Pt present on 2/22/21 to ER via ambulance at 1940. Upon presentation C/C hypotension Post COVID vaccine. Nurse notes Home Health nurse sent secondary to hypotension and hyperglycemia. Pt states back ached and was holding his head. Nurse noted pt had random petechiae over body and bruising to abdomen following injections received during recent hospitalization. (unknown hospitalization)
Preexisting Conditions: Hypertension, MI, CHF, DM, CRF, Thyroid, High Cholesterol, Prostate
Allergies: Shrimp, Red Man Syndrome, Cleocin, Clindamycin Clindamycin
Diagnostic Lab Data: 2/22/21: CBC WBC 11.74, H/H: 8.6/26.8. Glu $g625mg/dl, BUN 70, Creatnine $g4.10, Sodium <114, Potassium $g6.8, Cl 81, Troponin 0.583, CRP 1.5 BNP 26900, Lactate 8.4 CXR: Subtle inter stitial opacities could represent atelectasis, superimposed mild bronchitis or edema suspected.EKG: Ventricular Paced rhythm. Unsure if death applicable as adverse event secondary to vaccination. Physician noted Vascular Collapse post covid vaccine.
CDC 'Split Type':

Write-up: Pt received second Moderna Vaccination on 2/21/21 at 1:00 pm at Pharmacy. Pt present on 2/22/21 to ER via ambulance at 1940. Upon presentation C/C hypotension Post COVID vaccine. Nurse notes states that Home Health nurse sent patient to ER secondary to hypotension and hyperglycemia. Pt states back ached and was holding his head. Nurse noted pt had random petechiae over body and bruising to abdomen following injections received during recent hospitalization. (unknown hospitalization). Patient was treated with IVF bolus in addition to initiating Dopamine for hypotension, patient became agonal and daughter at bedside presented Adv. Directive, pt was DNR. Pt pronounced time of death was 2110pm. (Pt only reported a sore shoulder secondary to vaccine).


Changed on 5/14/2021

VAERS ID: 1050137 Before After
VAERS Form:2
Age:89.0
Sex:Male
Location:Louisiana
Vaccinated:2021-02-21
Onset:2021-02-22
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031M20A / 2 UN / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Back pain, Blood chloride decreased, Blood creatinine increased, Blood glucose increased, Blood lactic acid, Blood potassium increased, Blood sodium normal, Blood urea increased, C-reactive protein increased, C-reactive protein normal, Chest X-ray abnormal, Death, Electrocardiogram, Electrocardiogram abnormal, Haematocrit increased, Haemoglobin increased, Headache, Hyperglycaemia, Hypotension, Petechiae, White blood cell count increased, Agonal death struggle, Contusion, Brain natriuretic peptide increased, Pacemaker generated rhythm, Troponin, Lung opacity

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-23
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: Entresto, Metoprolol, Spironolactone, Vit D, Lasix, Flomax, Digoxin, Eliquis, Tradjenta, ASA, Novolog Flex pen, Levothyroxine, Vit B12, Lipitor, Aricept, Temazepam, Lorazepam, Glucose prn.
Current Illness: Fall on 2/15/21 pm resulting in skin tear requiring dressing. Pt Seen on 2/16 for skin tear repair secondary to fall the pm prior. Vital signs WNL. Pt returned on 2/20/21 for dressing change. Vital signs WNL. Pt received second Moderna Vaccination on 2/21/21 at 1:00 pm at Pharmacy. Pt present on 2/22/21 to ER via ambulance at 1940. Upon presentation C/C hypotension Post COVID vaccine. Nurse notes Home Health nurse sent secondary to hypotension and hyperglycemia. Pt states back ached and was holding his head. Nurse noted pt had random petechiae over body and bruising to abdomen following injections received during recent hospitalization. (unknown hospitalization)
Preexisting Conditions: Hypertension, MI, CHF, DM, CRF, Thyroid, High Cholesterol, Prostate
Allergies: Shrimp, Red Man Syndrome, Cleocin, Clindamycin Clindamycin
Diagnostic Lab Data: 2/22/21: CBC WBC 11.74, H/H: 8.6/26.8. Glu $g625mg/dl, BUN 70, Creatnine $g4.10, Sodium <114, Potassium $g6.8, Cl 81, Troponin 0.583, CRP 1.5 BNP 26900, Lactate 8.4 CXR: Subtle inter stitial opacities could represent atelectasis, superimposed mild bronchitis or edema suspected.EKG: Ventricular Paced rhythm. Unsure if death applicable as adverse event secondary to vaccination. Physician noted Vascular Collapse post covid vaccine.
CDC 'Split Type':

Write-up: Pt received second Moderna Vaccination on 2/21/21 at 1:00 pm at Pharmacy. Pt present on 2/22/21 to ER via ambulance at 1940. Upon presentation C/C hypotension Post COVID vaccine. Nurse notes states that Home Health nurse sent patient to ER secondary to hypotension and hyperglycemia. Pt states back ached and was holding his head. Nurse noted pt had random petechiae over body and bruising to abdomen following injections received during recent hospitalization. (unknown hospitalization). Patient was treated with IVF bolus in addition to initiating Dopamine for hypotension, patient became agonal and daughter at bedside presented Adv. Directive, pt was DNR. Pt pronounced time of death was 2110pm. (Pt only reported a sore shoulder secondary to vaccine).

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