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This is VAERS ID 1237511

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/23/2021

VAERS ID: 1237511
VAERS Form:2
Age:68.0
Sex:Male
Location:New York
Vaccinated:2021-04-18
Onset:2021-04-18
Submitted:0000-00-00
Entered:2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039B21A / 2 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Chest X-ray abnormal, Pneumonia aspiration, Unresponsive to stimuli, Vomiting, Anticoagulant therapy, Therapeutic hypothermia, Breath sounds abnormal, Endotracheal intubation, Computerised tomogram head normal, Lung opacity

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allopurinol 300mg tablet, amiodarone 200mg tablet, aspirin 81mg tablet, atorvastatin 40mg tablet, carvedilol 12.5mg tablet, clopidogrel 75mg tablet, folic acid 1mg, Levemir, Humalog, losartan-HCTZ 100/25mg tablet, omeprazole 40mg capsule, p
Current Illness:
Preexisting Conditions: Diabetes Mellitus Type 2, ICD Pacemaker, Renal disorder, gout
Allergies: Unable to assess at the time of hospitalization
Diagnostic Lab Data: CT Head done - no acute findings suggestive of stroke, hemorrhage Chest XRay showed Bilateral R$gL opacities and lung sounds coarse
CDC 'Split Type':

Write-up: Patient brought in by ambulance after cardiac arrest witnessed by patient''s wife at 4/19/21 1:37AM. Per ED, the wife reports he had complained of feeling weak over the last few days without clear reason, then this morning patient had episode of emesis after which he told wife to call 911 and then suddenly became unresponsive. In ED was intubated, started on hypothermia protocol, Patient sedated on Propofol and started on a heparin drip, clopidogrel, aspirin and empiric antibiotics for aspiration Pneumonia


Changed on 5/7/2021

VAERS ID: 1237511 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:New York
Vaccinated:2021-04-18
Onset:2021-04-18
Submitted:0000-00-00
Entered:2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039B21A / 2 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Chest X-ray abnormal, Pneumonia aspiration, Unresponsive to stimuli, Vomiting, Anticoagulant therapy, Therapeutic hypothermia, Breath sounds abnormal, Endotracheal intubation, Computerised tomogram head normal, Lung opacity

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allopurinol 300mg tablet, amiodarone 200mg tablet, aspirin 81mg tablet, atorvastatin 40mg tablet, carvedilol 12.5mg tablet, clopidogrel 75mg tablet, folic acid 1mg, Levemir, Humalog, losartan-HCTZ 100/25mg tablet, omeprazole 40mg capsule, p
Current Illness:
Preexisting Conditions: Diabetes Mellitus Type 2, ICD Pacemaker, Renal disorder, gout
Allergies: Unable to assess at the time of hospitalization hospitalization
Diagnostic Lab Data: CT Head done - no acute findings suggestive of stroke, hemorrhage Chest XRay showed Bilateral R$gL opacities and lung sounds coarse
CDC 'Split Type':

Write-up: Patient brought in by ambulance after cardiac arrest witnessed by patient''s wife at 4/19/21 1:37AM. Per ED, the wife reports he had complained of feeling weak over the last few days without clear reason, then this morning patient had episode of emesis after which he told wife to call 911 and then suddenly became unresponsive. In ED was intubated, started on hypothermia protocol, Patient sedated on Propofol and started on a heparin drip, clopidogrel, aspirin and empiric antibiotics for aspiration Pneumonia


Changed on 5/14/2021

VAERS ID: 1237511 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:New York
Vaccinated:2021-04-18
Onset:2021-04-18
Submitted:0000-00-00
Entered:2021-04-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039B21A / 2 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Chest X-ray abnormal, Pneumonia aspiration, Unresponsive to stimuli, Vomiting, Anticoagulant therapy, Therapeutic hypothermia, Breath sounds abnormal, Endotracheal intubation, Computerised tomogram head normal, Lung opacity

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-20
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allopurinol 300mg tablet, amiodarone 200mg tablet, aspirin 81mg tablet, atorvastatin 40mg tablet, carvedilol 12.5mg tablet, clopidogrel 75mg tablet, folic acid 1mg, Levemir, Humalog, losartan-HCTZ 100/25mg tablet, omeprazole 40mg capsule, p
Current Illness:
Preexisting Conditions: Diabetes Mellitus Type 2, ICD Pacemaker, Renal disorder, gout
Allergies: Unable to assess at the time of hospitalization hospitalization
Diagnostic Lab Data: CT Head done - no acute findings suggestive of stroke, hemorrhage Chest XRay showed Bilateral R$gL opacities and lung sounds coarse
CDC 'Split Type':

Write-up: Patient brought in by ambulance after cardiac arrest witnessed by patient''s wife at 4/19/21 1:37AM. Per ED, the wife reports he had complained of feeling weak over the last few days without clear reason, then this morning patient had episode of emesis after which he told wife to call 911 and then suddenly became unresponsive. In ED was intubated, started on hypothermia protocol, Patient sedated on Propofol and started on a heparin drip, clopidogrel, aspirin and empiric antibiotics for aspiration Pneumonia

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