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This is VAERS ID 1206437

History of Changes from the VAERS Wayback Machine

First Appeared on 7/2/2021

VAERS ID: 1206437
VAERS Form:2
Age:75.0
Sex:Male
Location:Foreign
Vaccinated:2021-01-27
Onset:2021-01-29
Submitted:0000-00-00
Entered:2021-04-14
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3000424 60 / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Death, Heart rate, International normalised ratio, Ultrasound scan, Blood pressure measurement

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-29
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: ATORVASTATIN CALCIUM ANHYDROUS; BILOL; DILTIAZEM HYDROCHLORIDE R; PHENPROCOUMON
Current Illness: Arterial hypertension; Atrial fibrillation paroxysmal (Paroxysmal atrial fibrillation/flutter - CHADs2 Score 1); Atrial flutter; Dyslipidemia; Hypertensive heart disease (mild concentric left ventricular hypertrophy); Prostatic hyperplasia
Preexisting Conditions: Medical History/Concurrent Conditions: Aneurysm (Asymptomatic infrarenal partially thrombosed abdominal aortic aneurysm Aneurysm of left common femoral artery); Aortic dissection (History of de/rebranching of internal iliac artery and bilateral endovascular aortic prosthesis May 2008); Aortic ectasia (Ectasia of internal and common iliac arteries, right common femoral and left popliteal artery); Arterial graft (Stent graft extension of the left iliac artery); Artery dissection (Asymptomatic dissection of distal superior mesenteric artery); Colonic polyp; Polyp removal (polyp removal in 2011 and 2014); Polypectomy (of 4 polyps); Renal cyst (Two large cortical renal cysts on left (9.9 and 5.1 cm),); Total hip replacement
Allergies:
Diagnostic Lab Data: Test Date: 20210127; Test Name: BP; Result Unstructured Data: Normal; Test Date: 20210127; Test Name: Pulse; Result Unstructured Data: Normal; Test Date: 20210112; Test Name: INR; Test Result: Inconclusive ; Result Unstructured Data: 2.8; Test Name: Abdominal sonogram; Test Result: Inconclusive ; Result Unstructured Data: Two large cortical renal cysts on left (9.9 and 5.1 cm)
CDC 'Split Type': CHMODERNATX, INC.MOD20210

Write-up: Death NOS; This case was received via an unknown source (no reference has been entered for a health authority or license partner) on 30-Mar-2021 and was forwarded to Moderna on 30-Mar-2021. This regulatory authority case was reported by a physician (subsequently medically confirmed) and describes the occurrence of DEATH (Death NOS) in a 75-year-old male patient who received mRNA-1273 (COVID-19 Vaccine Moderna) (batch no. 3000424 60) for COVID-19 vaccination. The patient''s past medical history included Aneurysm (Asymptomatic infrarenal partially thrombosed abdominal aortic aneurysm Aneurysm of left common femoral artery) in May 2008, Renal cyst (Two large cortical renal cysts on left (9.9 and 5.1 cm),), Colonic polyp on 13-Mar-2018, Aortic ectasia (Ectasia of internal and common iliac arteries, right common femoral and left popliteal artery), Artery dissection (Asymptomatic dissection of distal superior mesenteric artery), Polyp removal (polyp removal in 2011 and 2014) in 2011, Polypectomy (of 4 polyps) in August 2018, Total hip replacement on 15-Oct-2020, Aortic dissection (History of de/rebranching of internal iliac artery and bilateral endovascular aortic prosthesis May 2008) in May 2008 and Arterial graft (Stent graft extension of the left iliac artery) on 13-Mar-2018. Concurrent medical conditions included Atrial fibrillation paroxysmal (Paroxysmal atrial fibrillation/flutter - CHADs2 Score 1), Arterial hypertension, Hypertensive heart disease (mild concentric left ventricular hypertrophy), Dyslipidemia, Prostatic hyperplasia since June 2020 and Atrial flutter. Concomitant products included ATORVASTATIN CALCIUM ANHYDROUS, BISOPROLOL FUMARATE (BILOL), DILTIAZEM HYDROCHLORIDE (DILTIAZEM HYDROCHLORIDE R) and PHENPROCOUMON for an unknown indication. On 27-Jan-2021, the patient received first dose of mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular) 1 dosage form. Death occurred on 29-Jan-2021 The patient died on 29-Jan-2021. The cause of death was not reported. An autopsy was not performed. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 12-Jan-2021, International normalised ratio: 2.8 (Inconclusive) 2.8. On 27-Jan-2021, Blood pressure measurement: 117/80 (normal) Normal. On 27-Jan-2021, Heart rate: 73 (normal) Normal. On an unknown date, Ultrasound scan: abnormal (Inconclusive) Two large cortical renal cysts on left (9.9 and 5.1 cm). For mRNA-1273 (COVID-19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. No treatment information provided. Although a temporal association exists, provided information is not adequate to assess the causal association between the event and mRNA-1273. Causality is also confounded by the patient''s advanced age and medical history of Atrial fibrillation paroxysmal / atrial flutter- CHADs2 Score 1, Arterial hypertension, Hypertensive heart disease , Aneurysm and previous surgery for aortic dissection. The cause of death was not reported. Reporter did not allow further contact; Sender''s Comments: Although a temporal association exists, provided information is not adequate to assess the causal association between the event and mRNA-1273. Causality is also confounded by the patient''s advanced age and medical history of Atrial fibrillation paroxysmal / atrial flutter- CHADs2 Score 1, Arterial hypertension, Hypertensive heart disease , Aneurysm and previous surgery for aortic dissection. The cause of death was not reported.; Reported Cause(s) of Death: unknown cause of death

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