National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1085302

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1085302
VAERS Form:2
Age:79.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-02-26
Onset:2021-03-01
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Acute respiratory failure, Blood glucose increased, Cardiac failure acute, Death, Metabolic encephalopathy, Mechanical ventilation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-02
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg oral tablet Atorvastatin Calcium 80 MG Oral Tablet Empagliflozin (Jardiance) 10 MG Oral Tablet Fiber FluoGlimepiride 4 MG Oral Tablet Propranolol HCl (Propranolol HCl ER) 60 MG Oral Capsule Extended Release 24 Hour Sitagliptin
Current Illness:
Preexisting Conditions: Diabetes, Hyperlipidemia, Hypertension, Hyperpotassemia, Chronic Kidney Disease, Tremors
Allergies: Lisinopril
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was admitted to Hospital on 3/1/21. Blood Sugar of 758. Patient diagnosis with Acute respiratory failure with hypoxia and acute heart failure and Metabolic encephalopathy. Patient put on ventilator and passed away on 3/2/21 at 17:04.


Changed on 5/7/2021

VAERS ID: 1085302 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-02-26
Onset:2021-03-01
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Acute respiratory failure, Blood glucose increased, Cardiac failure acute, Death, Metabolic encephalopathy, Mechanical ventilation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-02
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg oral tablet Atorvastatin Calcium 80 MG Oral Tablet Empagliflozin (Jardiance) 10 MG Oral Tablet Fiber FluoGlimepiride 4 MG Oral Tablet Propranolol HCl (Propranolol HCl ER) 60 MG Oral Capsule Extended Release 24 Hour Sitagliptin
Current Illness:
Preexisting Conditions: Diabetes, Hyperlipidemia, Hypertension, Hyperpotassemia, Chronic Kidney Disease, Tremors
Allergies: Lisinopril Lisinopril
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was admitted to Hospital on 3/1/21. Blood Sugar of 758. Patient diagnosis with Acute respiratory failure with hypoxia and acute heart failure and Metabolic encephalopathy. Patient put on ventilator and passed away on 3/2/21 at 17:04.


Changed on 5/14/2021

VAERS ID: 1085302 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Wisconsin
Vaccinated:2021-02-26
Onset:2021-03-01
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013A21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Acute respiratory failure, Blood glucose increased, Cardiac failure acute, Death, Metabolic encephalopathy, Mechanical ventilation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-02
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg oral tablet Atorvastatin Calcium 80 MG Oral Tablet Empagliflozin (Jardiance) 10 MG Oral Tablet Fiber FluoGlimepiride 4 MG Oral Tablet Propranolol HCl (Propranolol HCl ER) 60 MG Oral Capsule Extended Release 24 Hour Sitagliptin
Current Illness:
Preexisting Conditions: Diabetes, Hyperlipidemia, Hypertension, Hyperpotassemia, Chronic Kidney Disease, Tremors
Allergies: Lisinopril Lisinopril
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was admitted to Hospital on 3/1/21. Blood Sugar of 758. Patient diagnosis with Acute respiratory failure with hypoxia and acute heart failure and Metabolic encephalopathy. Patient put on ventilator and passed away on 3/2/21 at 17:04.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1085302&WAYBACKHISTORY=ON

Government Disclaimer on use of this data


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166