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This is VAERS ID 1081279

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1081279
VAERS Form:2
Age:90.0
Sex:Male
Location:South Dakota
Vaccinated:2021-03-02
Onset:2021-03-02
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 LA / SYR

Administered by: Private      Purchased by: ??
Symptoms: Alanine aminotransferase normal, Albumin globulin ratio normal, Anion gap, Aspartate aminotransferase normal, Asthenia, Basophil count normal, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium normal, Blood chloride normal, Blood creatinine increased, Blood glucose normal, Blood magnesium normal, Blood potassium normal, Blood sodium increased, Blood urea increased, Carbon dioxide increased, Chest X-ray abnormal, Confusional state, Death, Dyspnoea, Eosinophil count normal, Fall, Fatigue, Globulin, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Lymphocyte count decreased, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin increased, Mean cell volume increased, Monocyte count increased, Neutrophil count normal, Platelet count normal, Protein total decreased, Red blood cell count decreased, White blood cell count normal, Blood urea nitrogen/creatinine ratio increased, Monocyte percentage increased, Lymphocyte percentage decreased, Red cell distribution width normal, Mean platelet volume normal, Eosinophil percentage, Neutrophil percentage, Basophil percentage, Lung opacity, Immature granulocyte count

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol sulfate 90 mcg/actuation aerosol inhaler (ProAir HFA) 2 puffs inhalation 4H PRN albuterol sulfate 2.5 mg NEB TID atorvastatin 40 mg tablet 0.5 tabs PO DAILY budesonide 0.5 mg/2 mL suspension for nebulization 1 vial NEB BID carved
Current Illness: Has underlying COPD, Was discharged from hospital 1/25/21 for pneumonia. Was declining prior to vaccination: more SOB, falling, abdomen bloated, coughing a little more, tired and weak.
Preexisting Conditions: COPD, CKD-3, CAD, Anemia, heart failure with reduced ejection fraction, a fib.
Allergies: atenolol, simvastatin, terazosin
Diagnostic Lab Data: "Hazy opacities on CHX -right lung. . WBC 6.1 K/uL (4.5-11.0) 03/02/21 17:00 RBC 3.10 M/uL (4.70-6.10) L 03/02/21 17:00 Hgb 10.5 g/dL (14.0-17.5) L 03/02/21 17:00 Hct 33.6 % (40.0-50.0) L 03/02/21 17:00 MCV 108.4 fL (80.0-100.0) H 03/02/21 17:00 MCH 33.9 pg (26.0-34.0) 03/02/21 17:00 MCHC 31.3 g/dL (32.0-36.0) L 03/02/21 17:00 RDW 12.1 % (11.5-15.0) 03/02/21 17:00 Plt Count 193 K/uL (140-450) 03/02/21 17:00 MPV 8.2 fL (7.0-11.0) 03/02/21 17:00 Immature Gran % (Auto) 0.3 % 03/02/21 17:00 Neut % (Auto) 70.6 % (40.0-75.0) 03/02/21 17:00 Lymph % (Auto) 11.9 % (5.0-50.0) 03/02/21 17:00 Mono % (Auto) 15.2 % (2.0-14.0) H 03/02/21 17:00 Eos % (Auto) 1.5 % (0.0-7.0) 03/02/21 17:00 Baso % (Auto) 0.5 % (0.0-2.0) 03/02/21 17:00 Abs Immat Gran (auto) 0.02 K/uL (<0.03) 03/02/21 17:00 Absolute Neuts (auto) 4.31 K/uL (1.80-7.70) 03/02/21 17:00 Absolute Lymphs (auto) 0.73 K/uL (1.00-4.80) L 03/02/21 17:00 Absolute Monos (auto) 0.93 K/uL (0.00-1.00) 03/02/21 17:00 Absolute Eos (auto) 0.09 K/uL (0.00-0.50) 03/02/21 17:00 Absolute Basos (auto) 0.03 K/uL (0.00-0.20) 03/02/21 17:00 Sodium 147 mmol/L (133-145) H 03/02/21 17:00 Potassium 4.5 mmol/L (3.5-5.1) 03/02/21 17:00 Chloride 98 mmol/L (98-109) 03/02/21 17:00 Carbon Dioxide 45 mmol/L (21-31) H 03/02/21 17:00 Anion Gap 4 mmol/L (3-15) 03/02/21 17:00 BUN 53 mg/dL (7-25) H 03/02/21 17:00 Creatinine 1.7 mg/dL (0.7-1.3) H 03/02/21 17:00 Estimated GFR (MDRD) 38 mL/Min (60-130) L 03/02/21 17:00 Est GFR (Cockcroft-G) 28 mL/Min ($g=50) L 03/02/21 17:00 Est GFR (CKD-EPI) 35 mL/Min (60-130) L 03/02/21 17:00 BUN/Creatinine Ratio 31.2 (10.0-20.0) H 03/02/21 17:00 Glucose 131 mg/dL (70-99) H 03/02/21 17:00 Calcium 9.5 mg/dL (8.6-10.3) 03/02/21 17:00 Magnesium 1.9 mg/dL (1.6-2.6) 03/02/21 17:00 Total Bilirubin 0.4 mg/dL (0.3-1.0) 03/02/21 17:00 AST 16 U/L (13-39) 03/02/21 17:00 ALT 11 U/L (4-33) 03/02/21 17:00 Alkaline Phosphatase 66 U/L (34-104) 03/02/21 17:00 Total Protein 6.2 g/dL (6.4-8.9) L 03/02/21 17:00 Albumin 3.5 g/dL (3.5-5.7) 03/02/21 17:00 Globulin 2.7 g/dL (1.5-4.5) 03/02/21 17:00 Albumin/Globulin Ratio 1.3 (0.8-2.0) 03/02/21 17:00
CDC 'Split Type':

Write-up: Patient seen by physician for weakness, tired, increase SOB, falls, increase confusion and then subsequently hospitalized . Patient then expired on 3/7/21.


Changed on 5/7/2021

VAERS ID: 1081279 Before After
VAERS Form:2
Age:90.0
Sex:Male
Location:South Dakota
Vaccinated:2021-03-02
Onset:2021-03-02
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 LA / SYR

Administered by: Private      Purchased by: ??
Symptoms: Alanine aminotransferase normal, Albumin globulin ratio normal, Anion gap, Aspartate aminotransferase normal, Asthenia, Basophil count normal, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium normal, Blood chloride normal, Blood creatinine increased, Blood glucose normal, Blood magnesium normal, Blood potassium normal, Blood sodium increased, Blood urea increased, Carbon dioxide increased, Chest X-ray abnormal, Confusional state, Death, Dyspnoea, Eosinophil count normal, Fall, Fatigue, Globulin, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Lymphocyte count decreased, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin increased, Mean cell volume increased, Monocyte count increased, Neutrophil count normal, Platelet count normal, Protein total decreased, Red blood cell count decreased, White blood cell count normal, Blood urea nitrogen/creatinine ratio increased, Monocyte percentage increased, Lymphocyte percentage decreased, Red cell distribution width normal, Mean platelet volume normal, Eosinophil percentage, Neutrophil percentage, Basophil percentage, Lung opacity, Immature granulocyte count

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol sulfate 90 mcg/actuation aerosol inhaler (ProAir HFA) 2 puffs inhalation 4H PRN albuterol sulfate 2.5 mg NEB TID atorvastatin 40 mg tablet 0.5 tabs PO DAILY budesonide 0.5 mg/2 mL suspension for nebulization 1 vial NEB BID carved
Current Illness: Has underlying COPD, Was discharged from hospital 1/25/21 for pneumonia. Was declining prior to vaccination: more SOB, falling, abdomen bloated, coughing a little more, tired and weak.
Preexisting Conditions: COPD, CKD-3, CAD, Anemia, heart failure with reduced ejection fraction, a fib.
Allergies: atenolol, simvastatin, terazosin terazosin
Diagnostic Lab Data: "Hazy opacities on CHX -right lung. . WBC 6.1 K/uL (4.5-11.0) 03/02/21 17:00 RBC 3.10 M/uL (4.70-6.10) L 03/02/21 17:00 Hgb 10.5 g/dL (14.0-17.5) L 03/02/21 17:00 Hct 33.6 % (40.0-50.0) L 03/02/21 17:00 MCV 108.4 fL (80.0-100.0) H 03/02/21 17:00 MCH 33.9 pg (26.0-34.0) 03/02/21 17:00 MCHC 31.3 g/dL (32.0-36.0) L 03/02/21 17:00 RDW 12.1 % (11.5-15.0) 03/02/21 17:00 Plt Count 193 K/uL (140-450) 03/02/21 17:00 MPV 8.2 fL (7.0-11.0) 03/02/21 17:00 Immature Gran % (Auto) 0.3 % 03/02/21 17:00 Neut % (Auto) 70.6 % (40.0-75.0) 03/02/21 17:00 Lymph % (Auto) 11.9 % (5.0-50.0) 03/02/21 17:00 Mono % (Auto) 15.2 % (2.0-14.0) H 03/02/21 17:00 Eos % (Auto) 1.5 % (0.0-7.0) 03/02/21 17:00 Baso % (Auto) 0.5 % (0.0-2.0) 03/02/21 17:00 Abs Immat Gran (auto) 0.02 K/uL (<0.03) 03/02/21 17:00 Absolute Neuts (auto) 4.31 K/uL (1.80-7.70) 03/02/21 17:00 Absolute Lymphs (auto) 0.73 K/uL (1.00-4.80) L 03/02/21 17:00 Absolute Monos (auto) 0.93 K/uL (0.00-1.00) 03/02/21 17:00 Absolute Eos (auto) 0.09 K/uL (0.00-0.50) 03/02/21 17:00 Absolute Basos (auto) 0.03 K/uL (0.00-0.20) 03/02/21 17:00 Sodium 147 mmol/L (133-145) H 03/02/21 17:00 Potassium 4.5 mmol/L (3.5-5.1) 03/02/21 17:00 Chloride 98 mmol/L (98-109) 03/02/21 17:00 Carbon Dioxide 45 mmol/L (21-31) H 03/02/21 17:00 Anion Gap 4 mmol/L (3-15) 03/02/21 17:00 BUN 53 mg/dL (7-25) H 03/02/21 17:00 Creatinine 1.7 mg/dL (0.7-1.3) H 03/02/21 17:00 Estimated GFR (MDRD) 38 mL/Min (60-130) L 03/02/21 17:00 Est GFR (Cockcroft-G) 28 mL/Min ($g=50) L 03/02/21 17:00 Est GFR (CKD-EPI) 35 mL/Min (60-130) L 03/02/21 17:00 BUN/Creatinine Ratio 31.2 (10.0-20.0) H 03/02/21 17:00 Glucose 131 mg/dL (70-99) H 03/02/21 17:00 Calcium 9.5 mg/dL (8.6-10.3) 03/02/21 17:00 Magnesium 1.9 mg/dL (1.6-2.6) 03/02/21 17:00 Total Bilirubin 0.4 mg/dL (0.3-1.0) 03/02/21 17:00 AST 16 U/L (13-39) 03/02/21 17:00 ALT 11 U/L (4-33) 03/02/21 17:00 Alkaline Phosphatase 66 U/L (34-104) 03/02/21 17:00 Total Protein 6.2 g/dL (6.4-8.9) L 03/02/21 17:00 Albumin 3.5 g/dL (3.5-5.7) 03/02/21 17:00 Globulin 2.7 g/dL (1.5-4.5) 03/02/21 17:00 Albumin/Globulin Ratio 1.3 (0.8-2.0) 03/02/21 17:00
CDC 'Split Type':

Write-up: Patient seen by physician for weakness, tired, increase SOB, falls, increase confusion and then subsequently hospitalized . Patient then expired on 3/7/21.


Changed on 5/14/2021

VAERS ID: 1081279 Before After
VAERS Form:2
Age:90.0
Sex:Male
Location:South Dakota
Vaccinated:2021-03-02
Onset:2021-03-02
Submitted:0000-00-00
Entered:2021-03-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 010A21A / 2 LA / SYR

Administered by: Private      Purchased by: ??
Symptoms: Alanine aminotransferase normal, Albumin globulin ratio normal, Anion gap, Aspartate aminotransferase normal, Asthenia, Basophil count normal, Blood albumin normal, Blood alkaline phosphatase normal, Blood bilirubin normal, Blood calcium normal, Blood chloride normal, Blood creatinine increased, Blood glucose normal, Blood magnesium normal, Blood potassium normal, Blood sodium increased, Blood urea increased, Carbon dioxide increased, Chest X-ray abnormal, Confusional state, Death, Dyspnoea, Eosinophil count normal, Fall, Fatigue, Globulin, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Lymphocyte count decreased, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin increased, Mean cell volume increased, Monocyte count increased, Neutrophil count normal, Platelet count normal, Protein total decreased, Red blood cell count decreased, White blood cell count normal, Blood urea nitrogen/creatinine ratio increased, Monocyte percentage increased, Lymphocyte percentage decreased, Red cell distribution width normal, Mean platelet volume normal, Eosinophil percentage, Neutrophil percentage, Basophil percentage, Lung opacity, Immature granulocyte count

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-07
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? Yes, days: 5     Extended hospital stay? No
Previous Vaccinations:
Other Medications: albuterol sulfate 90 mcg/actuation aerosol inhaler (ProAir HFA) 2 puffs inhalation 4H PRN albuterol sulfate 2.5 mg NEB TID atorvastatin 40 mg tablet 0.5 tabs PO DAILY budesonide 0.5 mg/2 mL suspension for nebulization 1 vial NEB BID carved
Current Illness: Has underlying COPD, Was discharged from hospital 1/25/21 for pneumonia. Was declining prior to vaccination: more SOB, falling, abdomen bloated, coughing a little more, tired and weak.
Preexisting Conditions: COPD, CKD-3, CAD, Anemia, heart failure with reduced ejection fraction, a fib.
Allergies: atenolol, simvastatin, terazosin terazosin
Diagnostic Lab Data: "Hazy opacities on CHX -right lung. . WBC 6.1 K/uL (4.5-11.0) 03/02/21 17:00 RBC 3.10 M/uL (4.70-6.10) L 03/02/21 17:00 Hgb 10.5 g/dL (14.0-17.5) L 03/02/21 17:00 Hct 33.6 % (40.0-50.0) L 03/02/21 17:00 MCV 108.4 fL (80.0-100.0) H 03/02/21 17:00 MCH 33.9 pg (26.0-34.0) 03/02/21 17:00 MCHC 31.3 g/dL (32.0-36.0) L 03/02/21 17:00 RDW 12.1 % (11.5-15.0) 03/02/21 17:00 Plt Count 193 K/uL (140-450) 03/02/21 17:00 MPV 8.2 fL (7.0-11.0) 03/02/21 17:00 Immature Gran % (Auto) 0.3 % 03/02/21 17:00 Neut % (Auto) 70.6 % (40.0-75.0) 03/02/21 17:00 Lymph % (Auto) 11.9 % (5.0-50.0) 03/02/21 17:00 Mono % (Auto) 15.2 % (2.0-14.0) H 03/02/21 17:00 Eos % (Auto) 1.5 % (0.0-7.0) 03/02/21 17:00 Baso % (Auto) 0.5 % (0.0-2.0) 03/02/21 17:00 Abs Immat Gran (auto) 0.02 K/uL (<0.03) 03/02/21 17:00 Absolute Neuts (auto) 4.31 K/uL (1.80-7.70) 03/02/21 17:00 Absolute Lymphs (auto) 0.73 K/uL (1.00-4.80) L 03/02/21 17:00 Absolute Monos (auto) 0.93 K/uL (0.00-1.00) 03/02/21 17:00 Absolute Eos (auto) 0.09 K/uL (0.00-0.50) 03/02/21 17:00 Absolute Basos (auto) 0.03 K/uL (0.00-0.20) 03/02/21 17:00 Sodium 147 mmol/L (133-145) H 03/02/21 17:00 Potassium 4.5 mmol/L (3.5-5.1) 03/02/21 17:00 Chloride 98 mmol/L (98-109) 03/02/21 17:00 Carbon Dioxide 45 mmol/L (21-31) H 03/02/21 17:00 Anion Gap 4 mmol/L (3-15) 03/02/21 17:00 BUN 53 mg/dL (7-25) H 03/02/21 17:00 Creatinine 1.7 mg/dL (0.7-1.3) H 03/02/21 17:00 Estimated GFR (MDRD) 38 mL/Min (60-130) L 03/02/21 17:00 Est GFR (Cockcroft-G) 28 mL/Min ($g=50) L 03/02/21 17:00 Est GFR (CKD-EPI) 35 mL/Min (60-130) L 03/02/21 17:00 BUN/Creatinine Ratio 31.2 (10.0-20.0) H 03/02/21 17:00 Glucose 131 mg/dL (70-99) H 03/02/21 17:00 Calcium 9.5 mg/dL (8.6-10.3) 03/02/21 17:00 Magnesium 1.9 mg/dL (1.6-2.6) 03/02/21 17:00 Total Bilirubin 0.4 mg/dL (0.3-1.0) 03/02/21 17:00 AST 16 U/L (13-39) 03/02/21 17:00 ALT 11 U/L (4-33) 03/02/21 17:00 Alkaline Phosphatase 66 U/L (34-104) 03/02/21 17:00 Total Protein 6.2 g/dL (6.4-8.9) L 03/02/21 17:00 Albumin 3.5 g/dL (3.5-5.7) 03/02/21 17:00 Globulin 2.7 g/dL (1.5-4.5) 03/02/21 17:00 Albumin/Globulin Ratio 1.3 (0.8-2.0) 03/02/21 17:00
CDC 'Split Type':

Write-up: Patient seen by physician for weakness, tired, increase SOB, falls, increase confusion and then subsequently hospitalized . Patient then expired on 3/7/21.

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