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This is VAERS ID 1221163

History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1221163
VAERS Form:2
Age:72.0
Sex:Male
Location:Colorado
Vaccinated:2021-02-13
Onset:2021-03-21
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Gait disturbance, Myocardial infarction, Pain, Bedridden

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-21
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: GABAPENTIN
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COPD; Diabetes; Disabled spouse (100% disable); Neurological disorder NOS
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: heart attack; couldnt walk; couldnt get out of bed; body ache and pains; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of MYOCARDIAL INFARCTION (heart attack) in a 72-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 030M20A and 033A21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Neurological disorder NOS, Diabetes, peripheral artery disease, Disabled spouse (100% disable) and COPD. Concomitant products included GABAPENTIN for an unknown indication. On 13-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 20-Mar-2021, received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 2 dosage form. On 21-Mar-2021, the patient experienced MYOCARDIAL INFARCTION (heart attack) (seriousness criterion death), GAIT DISTURBANCE (couldnt walk), BEDRIDDEN (couldnt get out of bed) and PAIN (body ache and pains). The patient died on 21-Mar-2021. The reported cause of death was Heart attack. It is unknown if an autopsy was performed. At the time of death, GAIT DISTURBANCE (couldnt walk), BEDRIDDEN (couldnt get out of bed) and PAIN (body ache and pains) outcome was unknown. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. The patient had a medical condition of "agent orange". The patient was a veteran. Treatment included for the events was acetaminophen (Tylenol). Based on the current available information and the temporal association between the product use and the start date of the events a causal relationship cannot be excluded. This case was linked to US-MODERNATX, INC.-MOD-2021-075051 (Linked Report).; Sender''s Comments: Based on the current available information and the temporal association between the product use and the start date of the events a causal relationship cannot be excluded. US-MODERNATX, INC.-MOD-2021-075051:Case for second dose; Reported Cause(s) of Death: Heart attack


Changed on 5/7/2021

VAERS ID: 1221163 Before After
VAERS Form:2
Age:72.0
Sex:Male
Location:Colorado
Vaccinated:2021-02-13
Onset:2021-03-21
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Gait disturbance, Myocardial infarction, Pain, Bedridden

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-21
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: GABAPENTIN
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COPD; Diabetes; Disabled spouse (100% disable); Neurological disorder NOS
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: heart attack; couldnt walk; couldnt get out of bed; body ache and pains; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of MYOCARDIAL INFARCTION (heart attack) in a 72-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 030M20A and 033A21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Neurological disorder NOS, Diabetes, peripheral artery disease, Disabled spouse (100% disable) and COPD. Concomitant products included GABAPENTIN for an unknown indication. On 13-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 20-Mar-2021, received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 2 dosage form. On 21-Mar-2021, the patient experienced MYOCARDIAL INFARCTION (heart attack) (seriousness criterion death), GAIT DISTURBANCE (couldnt walk), BEDRIDDEN (couldnt get out of bed) and PAIN (body ache and pains). The patient died on 21-Mar-2021. The reported cause of death was Heart attack. It is unknown if an autopsy was performed. At the time of death, GAIT DISTURBANCE (couldnt walk), BEDRIDDEN (couldnt get out of bed) and PAIN (body ache and pains) outcome was unknown. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. The patient had a medical condition of "agent orange". The patient was a veteran. Treatment included for the events was acetaminophen (Tylenol). Based on the current available information and the temporal association between the product use and the start date of the events a causal relationship cannot be excluded. This case was linked to US-MODERNATX, INC.-MOD-2021-075051 (Linked Report).; Sender''s Comments: Based on the current available information and the temporal association between the product use and the start date of the events a causal relationship cannot be excluded. US-MODERNATX, INC.-MOD-2021-075051:Case for second dose; Reported Cause(s) of Death: Heart attack


Changed on 5/14/2021

VAERS ID: 1221163 Before After
VAERS Form:2
Age:72.0
Sex:Male
Location:Colorado
Vaccinated:2021-02-13
Onset:2021-03-21
Submitted:0000-00-00
Entered:2021-04-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Gait disturbance, Myocardial infarction, Pain, Bedridden

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-21
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: GABAPENTIN
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: COPD; Diabetes; Disabled spouse (100% disable); Neurological disorder NOS
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: heart attack; couldnt walk; couldnt get out of bed; body ache and pains; This spontaneous case was reported by a consumer (subsequently medically confirmed) and describes the occurrence of MYOCARDIAL INFARCTION (heart attack) in a 72-year-old male patient who received mRNA-1273 (Moderna COVID-19 Vaccine) (batch nos. 030M20A and 033A21A) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. Concurrent medical conditions included Neurological disorder NOS, Diabetes, peripheral artery disease, Disabled spouse (100% disable) and COPD. Concomitant products included GABAPENTIN for an unknown indication. On 13-Feb-2021, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 20-Mar-2021, received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) dosage was changed to 2 dosage form. On 21-Mar-2021, the patient experienced MYOCARDIAL INFARCTION (heart attack) (seriousness criterion death), GAIT DISTURBANCE (couldnt walk), BEDRIDDEN (couldnt get out of bed) and PAIN (body ache and pains). The patient died on 21-Mar-2021. The reported cause of death was Heart attack. It is unknown if an autopsy was performed. At the time of death, GAIT DISTURBANCE (couldnt walk), BEDRIDDEN (couldnt get out of bed) and PAIN (body ache and pains) outcome was unknown. The action taken with mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) was unknown. For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. The patient had a medical condition of "agent orange". The patient was a veteran. Treatment included for the events was acetaminophen (Tylenol). Based on the current available information and the temporal association between the product use and the start date of the events a causal relationship cannot be excluded. This case was linked to US-MODERNATX, INC.-MOD-2021-075051 (Linked Report).; Sender''s Comments: Based on the current available information and the temporal association between the product use and the start date of the events a causal relationship cannot be excluded. US-MODERNATX, INC.-MOD-2021-075051:Case for second dose; Reported Cause(s) of Death: Heart attack

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1221163&WAYBACKHISTORY=ON

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