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This is VAERS ID 1095238

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1095238
VAERS Form:2
Age:69.0
Sex:Male
Location:Oklahoma
Vaccinated:2021-03-08
Onset:2021-03-09
Submitted:0000-00-00
Entered:2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac failure congestive, Condition aggravated, Death, Dyspnoea, Oedema, Oxygen saturation decreased, Resuscitation, Tachycardia, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-09
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? No
Previous Vaccinations:
Other Medications: Lasix 40 mg daily, Potassium 10 meq daily, Novolin 70/30 insulin, gabapentin 600 mg BID, metformin 500mg BID, Naprosyn 500 mg BID, Lisinopril 20 mg daily, incruse ellipta and fluticasone/ salmeterol inhalers
Current Illness: covid positive 9/14/20, recently worsening of congestive heart failure with edema and shortness of breath for previous week
Preexisting Conditions: sarcoidosis, COPD, diabetes, HTN, congestive heart failure
Allergies: none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient at the time of vaccination on 3-8-21 has having issues with shortness of breath and edema consistent with congestive heart failure, the following day on 3-9-21, he was having more issues with shortness of breath, tachycardia, low O2 saturation. He was given meds in the clinic and monitored until he was feeling better with increased O2 sats. He was found unresponsive on his housing unit one hour later and failed to respond to resuscitation efforts and was pronounced expired at 1047.


Changed on 5/7/2021

VAERS ID: 1095238 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:Oklahoma
Vaccinated:2021-03-08
Onset:2021-03-09
Submitted:0000-00-00
Entered:2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac failure congestive, Condition aggravated, Death, Dyspnoea, Oedema, Oxygen saturation decreased, Resuscitation, Tachycardia, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-09
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? No
Previous Vaccinations:
Other Medications: Lasix 40 mg daily, Potassium 10 meq daily, Novolin 70/30 insulin, gabapentin 600 mg BID, metformin 500mg BID, Naprosyn 500 mg BID, Lisinopril 20 mg daily, incruse ellipta and fluticasone/ salmeterol inhalers
Current Illness: covid positive 9/14/20, recently worsening of congestive heart failure with edema and shortness of breath for previous week
Preexisting Conditions: sarcoidosis, COPD, diabetes, HTN, congestive heart failure
Allergies: none none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient at the time of vaccination on 3-8-21 has having issues with shortness of breath and edema consistent with congestive heart failure, the following day on 3-9-21, he was having more issues with shortness of breath, tachycardia, low O2 saturation. He was given meds in the clinic and monitored until he was feeling better with increased O2 sats. He was found unresponsive on his housing unit one hour later and failed to respond to resuscitation efforts and was pronounced expired at 1047.


Changed on 5/14/2021

VAERS ID: 1095238 Before After
VAERS Form:2
Age:69.0
Sex:Male
Location:Oklahoma
Vaccinated:2021-03-08
Onset:2021-03-09
Submitted:0000-00-00
Entered:2021-03-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 032M20A / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac failure congestive, Condition aggravated, Death, Dyspnoea, Oedema, Oxygen saturation decreased, Resuscitation, Tachycardia, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-09
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? No
Previous Vaccinations:
Other Medications: Lasix 40 mg daily, Potassium 10 meq daily, Novolin 70/30 insulin, gabapentin 600 mg BID, metformin 500mg BID, Naprosyn 500 mg BID, Lisinopril 20 mg daily, incruse ellipta and fluticasone/ salmeterol inhalers
Current Illness: covid positive 9/14/20, recently worsening of congestive heart failure with edema and shortness of breath for previous week
Preexisting Conditions: sarcoidosis, COPD, diabetes, HTN, congestive heart failure
Allergies: none none
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient at the time of vaccination on 3-8-21 has having issues with shortness of breath and edema consistent with congestive heart failure, the following day on 3-9-21, he was having more issues with shortness of breath, tachycardia, low O2 saturation. He was given meds in the clinic and monitored until he was feeling better with increased O2 sats. He was found unresponsive on his housing unit one hour later and failed to respond to resuscitation efforts and was pronounced expired at 1047.

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