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This is VAERS ID 1236408

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1236408
VAERS Form:2
Age:78.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-22
Onset:2021-03-14
Submitted:0000-00-00
Entered:2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cholelithiasis, Colonoscopy abnormal, Death, Diverticulum, Intensive care, Pleural effusion, Umbilical hernia, Computerised tomogram abdomen abnormal, Ulcer haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death Narrative: Patient was not previously Covid positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there and ADR that occurred between the observation period and the date of death. Patient was hospitalized in early 02/2021 at Medical Center in the ICU for a bleeding ulcer. Was inpatient for over a month, but do not have records due to it being outside facility. Received a colonoscopy report which showed. diverticulosis and CT of abdomen showing pleural effusion, umbilical hernia and gallstones. Notable comorbidities include emphysema, CKD, CAD, ICM, and T2DM.


Changed on 5/7/2021

VAERS ID: 1236408 Before After
VAERS Form:2
Age:78.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-22
Onset:2021-03-14
Submitted:0000-00-00
Entered:2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cholelithiasis, Colonoscopy abnormal, Death, Diverticulum, Intensive care, Pleural effusion, Umbilical hernia, Computerised tomogram abdomen abnormal, Ulcer haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death Narrative: Patient was not previously Covid positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there and ADR that occurred between the observation period and the date of death. Patient was hospitalized in early 02/2021 at Medical Center in the ICU for a bleeding ulcer. Was inpatient for over a month, but do not have records due to it being outside facility. Received a colonoscopy report which showed. diverticulosis and CT of abdomen showing pleural effusion, umbilical hernia and gallstones. Notable comorbidities include emphysema, CKD, CAD, ICM, and T2DM.


Changed on 5/14/2021

VAERS ID: 1236408 Before After
VAERS Form:2
Age:78.0
Sex:Male
Location:Unknown
Vaccinated:2021-01-22
Onset:2021-03-14
Submitted:0000-00-00
Entered:2021-04-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 013L20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Cholelithiasis, Colonoscopy abnormal, Death, Diverticulum, Intensive care, Pleural effusion, Umbilical hernia, Computerised tomogram abdomen abnormal, Ulcer haemorrhage

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death Narrative: Patient was not previously Covid positive and did not have any predisposing factors(PMH, allergies, etc.) for experiencing an adverse drug event. The ADR did not occur at the time of the administration of the vaccine nor was there and ADR that occurred between the observation period and the date of death. Patient was hospitalized in early 02/2021 at Medical Center in the ICU for a bleeding ulcer. Was inpatient for over a month, but do not have records due to it being outside facility. Received a colonoscopy report which showed. diverticulosis and CT of abdomen showing pleural effusion, umbilical hernia and gallstones. Notable comorbidities include emphysema, CKD, CAD, ICM, and T2DM.

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