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This is VAERS ID 1271212

History of Changes from the VAERS Wayback Machine

First Appeared on 5/28/2021

VAERS ID: 1271212
VAERS Form:2
Age:29.0
Sex:Male
Location:Puerto Rico
Vaccinated:2021-04-12
Onset:2021-04-22
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other      Purchased by: ??
Symptoms: Cardiogenic shock, Death, Echocardiogram, Laboratory test

Life Threatening? Yes
Birth Defect? No
Died? No
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Clonazepam, Ambien, Transene
Current Illness: Asma , Anxietyy
Preexisting Conditions: On admission time was found with ejection fraction of 16%
Allergies: NONE
Diagnostic Lab Data: ECHO-CARDIOGRAM BLOOD TEST
CDC 'Split Type':

Write-up: PATIENT DEVELOP CARDIOGENIC SHOCK AFTER RECEIVED FIRST DOSE OF MODERNA VACCINE ON THURSDAY 29 2021 PATIENT DIED


Changed on 6/25/2021

VAERS ID: 1271212 Before After
VAERS Form:2
Age:29.0
Sex:Male
Location:Puerto Rico
Vaccinated:2021-04-12
Onset:2021-04-22
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / -

Administered by: Other      Purchased by: ??
Symptoms: Cardiogenic shock, Death, Echocardiogram, Laboratory test

Life Threatening? Yes
Birth Defect? No
Died? No Yes
   Date died:0000-00-00
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: 2     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Clonazepam, Ambien, Transene
Current Illness: Asma , Anxietyy
Preexisting Conditions: On admission time was found with ejection fraction of 16%
Allergies: NONE
Diagnostic Lab Data: ECHO-CARDIOGRAM BLOOD TEST
CDC 'Split Type':

Write-up: PATIENT DEVELOP CARDIOGENIC SHOCK AFTER RECEIVED FIRST DOSE OF MODERNA VACCINE ON THURSDAY 29 2021 PATIENT DIED

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1271212&WAYBACKHISTORY=ON

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