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This is VAERS ID 1218467

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1218467
VAERS Form:2
Age:67.0
Sex:Male
Location:Kentucky
Vaccinated:2021-03-14
Onset:2021-03-14
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Acute pulmonary oedema, Acute respiratory failure, Catheterisation cardiac, Sepsis, Vitamin B12 deficiency, Catheter placement, Troponin increased, Acute left ventricular failure, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-06
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: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient hospitalized Hospital Admission Diagnoses: Severe sepsis (CMS/HCC) [A41.9, R65.20] Discharge Diagnosis: Patient Active Problem List Diagnosis Date Noted *Elevated troponin 03/30/2021 *B12 deficiency 03/30/2021 *Acute systolic heart failure (CMS/HCC) 03/25/2021 Discharge Diagnoses: Patient Active Problem List Diagnosis Date Noted *Elevated troponin 03/30/2021 *B12 deficiency 03/30/2021 *Acute systolic heart failure (CMS/HCC) 03/25/2021 *Acute respiratory failure with hypoxia (CMS/HCC) 03/24/2021 *Acute pulmonary edema (CMS/HCC) 03/24/2021 *IVH (Intraventricular hemorrhage) (CMS/HCC) 06/06/2018 *Brain edema (CMS/HCC) 06/06/2018 *Brain compression (CMS/HCC) 06/06/2018 *Benign essential HTN *Coronary artery disease * Type 2 diabetes mellitus with hemoglobin A1c goal of less than 7.0% (CMS/HCC) *Nontraumatic right thalamic hemorrhage (HCC) 06/05/2018 Consults: IP CONSULT TO PULMONOLOGY IP CONSULT TO CARDIOLOGY INPATIENT CONSULT TO PHARMACY INPATIENT CONSULT TO PHARMACY IP CONSULT TO NUTRITION SERVICES IP CONSULT TO NUTRITION SERVICES Procedures: Intubation Catheterization Significant Diagnostic Studies: Cardiac Catheterization


Changed on 5/7/2021

VAERS ID: 1218467 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Kentucky
Vaccinated:2021-03-14
Onset:2021-03-14
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Acute pulmonary oedema, Acute respiratory failure, Catheterisation cardiac, Sepsis, Vitamin B12 deficiency, Catheter placement, Troponin increased, Acute left ventricular failure, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-06
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: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient hospitalized Hospital Admission Diagnoses: Severe sepsis (CMS/HCC) [A41.9, R65.20] Discharge Diagnosis: Patient Active Problem List Diagnosis Date Noted *Elevated troponin 03/30/2021 *B12 deficiency 03/30/2021 *Acute systolic heart failure (CMS/HCC) 03/25/2021 Discharge Diagnoses: Patient Active Problem List Diagnosis Date Noted *Elevated troponin 03/30/2021 *B12 deficiency 03/30/2021 *Acute systolic heart failure (CMS/HCC) 03/25/2021 *Acute respiratory failure with hypoxia (CMS/HCC) 03/24/2021 *Acute pulmonary edema (CMS/HCC) 03/24/2021 *IVH (Intraventricular hemorrhage) (CMS/HCC) 06/06/2018 *Brain edema (CMS/HCC) 06/06/2018 *Brain compression (CMS/HCC) 06/06/2018 *Benign essential HTN *Coronary artery disease * Type 2 diabetes mellitus with hemoglobin A1c goal of less than 7.0% (CMS/HCC) *Nontraumatic right thalamic hemorrhage (HCC) 06/05/2018 Consults: IP CONSULT TO PULMONOLOGY IP CONSULT TO CARDIOLOGY INPATIENT CONSULT TO PHARMACY INPATIENT CONSULT TO PHARMACY IP CONSULT TO NUTRITION SERVICES IP CONSULT TO NUTRITION SERVICES Procedures: Intubation Catheterization Significant Diagnostic Studies: Cardiac Catheterization


Changed on 5/14/2021

VAERS ID: 1218467 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Kentucky
Vaccinated:2021-03-14
Onset:2021-03-14
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026A21A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Acute pulmonary oedema, Acute respiratory failure, Catheterisation cardiac, Sepsis, Vitamin B12 deficiency, Catheter placement, Troponin increased, Acute left ventricular failure, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-06
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: 14     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient hospitalized Hospital Admission Diagnoses: Severe sepsis (CMS/HCC) [A41.9, R65.20] Discharge Diagnosis: Patient Active Problem List Diagnosis Date Noted *Elevated troponin 03/30/2021 *B12 deficiency 03/30/2021 *Acute systolic heart failure (CMS/HCC) 03/25/2021 Discharge Diagnoses: Patient Active Problem List Diagnosis Date Noted *Elevated troponin 03/30/2021 *B12 deficiency 03/30/2021 *Acute systolic heart failure (CMS/HCC) 03/25/2021 *Acute respiratory failure with hypoxia (CMS/HCC) 03/24/2021 *Acute pulmonary edema (CMS/HCC) 03/24/2021 *IVH (Intraventricular hemorrhage) (CMS/HCC) 06/06/2018 *Brain edema (CMS/HCC) 06/06/2018 *Brain compression (CMS/HCC) 06/06/2018 *Benign essential HTN *Coronary artery disease * Type 2 diabetes mellitus with hemoglobin A1c goal of less than 7.0% (CMS/HCC) *Nontraumatic right thalamic hemorrhage (HCC) 06/05/2018 Consults: IP CONSULT TO PULMONOLOGY IP CONSULT TO CARDIOLOGY INPATIENT CONSULT TO PHARMACY INPATIENT CONSULT TO PHARMACY IP CONSULT TO NUTRITION SERVICES IP CONSULT TO NUTRITION SERVICES Procedures: Intubation Catheterization Significant Diagnostic Studies: Cardiac Catheterization

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