National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 5/7/2021 release of VAERS data:

This is VAERS ID 1124363



Case Details

VAERS ID: 1124363 (history)  
Form: Version 2.0  
Age: 65.0  
Sex: Male  
Location: Hawaii  
Vaccinated:2021-03-06
Onset:2021-03-20
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-03-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA W1010A21A / UNK LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Resuscitation, Sudden cardiac death, Syncope
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lipitor 10 mg tablet 1 tab(s) orally once a day at bedtime Benicar HCT 25 mg-40 mg tablet 1 tab(s) orally once a day metformin 1000 mg tablet 1 tab(s) orally BID Tenormin 50 mg tablet 1 tab(s) orally once a day ASA 81mg enteric
Current Illness: none
Preexisting Conditions: type 2 diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, obesity, alcohol abuse
Allergies: none
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient died at home. apparently he awoke in the middle of the night and asked for help, then collapsed. CPR failed. patient and family did not want an autopsy. suspect sudden cardiac death


New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1124363


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