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This is VAERS ID 1271626

History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1271626
VAERS Form:2
Age:78.0
Sex:Male
Location:Georgia
Vaccinated:2021-04-21
Onset:2021-04-22
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0071321A / 2 - / -

Administered by: Private      Purchased by: ??
Symptoms: Body temperature increased, Chest pain, Fall, Gait inability, Headache, Malaise, Nausea, Rhabdomyolysis, Vomiting, Laboratory test, Oropharyngeal pain

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-29
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: FLOMAX 0.4MG DAILY IBUPROFEN AS NEEDED
Current Illness: NONE REPORTED
Preexisting Conditions: HYPERLIPIDEMIA
Allergies: NO KNOWN DRUG ALLERGIES REPORTED
Diagnostic Lab Data: LAB TESTING AT MLMC DURING ER AND OBS STAY 04/24-04/26/2021 AND 04/27/2021-04/28/2021
CDC 'Split Type':

Write-up: SPOUSE REPORTS THE FOLLOWING FOR PATIENT 4/21/2021 @ 9PM GENERAL MALAISE 4/22/2021 APPROX 4AM SEVERE HEADACHE TOOK IBUPROFEN 4/23/2021 AFTER LUNCH, PATIENT WAS UNABLE TO WALK AS PREVIOUS AND HAD 4 FALLS, ALSO COMPLAINED OF A SORE THROAT. 4/24/2021 DID NOT FEEL WELL, TEMP UP TO 100.4, NAUSEA AND VOMITTING X 1 AND CHEST PAIN, CALLED EMS AND WAS TRANSPORTED TO MEDICAL CENTER ER. 4/26/2021 PATIENT WAS DISCHAGED HOME AFTER TREATMENT FOR RHABDOMYOLYSIS AND RETURNED TO THE HOSTPITAL AGAIN ON 04/27/2021 WITH RHABDOMYOLYSIS AS PRIMARY DIAGNSOSIS. RESIDENT DISCHARGED TO SNF ON 04/28/2021.


Changed on 5/7/2021

VAERS ID: 1271626 Before After
VAERS Form:2
Age:78.0
Sex:Male
Location:Georgia
Vaccinated:2021-04-21
Onset:2021-04-22
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0071321A / 2 - / -

Administered by: Private      Purchased by: ??
Symptoms: Body temperature increased, Chest pain, Fall, Gait inability, Headache, Malaise, Nausea, Rhabdomyolysis, Vomiting, Laboratory test, Oropharyngeal pain

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-29
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: FLOMAX 0.4MG DAILY IBUPROFEN AS NEEDED
Current Illness: NONE REPORTED
Preexisting Conditions: HYPERLIPIDEMIA
Allergies: NO KNOWN DRUG ALLERGIES REPORTED REPORTED
Diagnostic Lab Data: LAB TESTING AT MLMC DURING ER AND OBS STAY 04/24-04/26/2021 AND 04/27/2021-04/28/2021
CDC 'Split Type':

Write-up: SPOUSE REPORTS THE FOLLOWING FOR PATIENT 4/21/2021 @ 9PM GENERAL MALAISE 4/22/2021 APPROX 4AM SEVERE HEADACHE TOOK IBUPROFEN 4/23/2021 AFTER LUNCH, PATIENT WAS UNABLE TO WALK AS PREVIOUS AND HAD 4 FALLS, ALSO COMPLAINED OF A SORE THROAT. 4/24/2021 DID NOT FEEL WELL, TEMP UP TO 100.4, NAUSEA AND VOMITTING X 1 AND CHEST PAIN, CALLED EMS AND WAS TRANSPORTED TO MEDICAL CENTER ER. 4/26/2021 PATIENT WAS DISCHAGED HOME AFTER TREATMENT FOR RHABDOMYOLYSIS AND RETURNED TO THE HOSTPITAL AGAIN ON 04/27/2021 WITH RHABDOMYOLYSIS AS PRIMARY DIAGNSOSIS. RESIDENT DISCHARGED TO SNF ON 04/28/2021.


Changed on 5/14/2021

VAERS ID: 1271626 Before After
VAERS Form:2
Age:78.0
Sex:Male
Location:Georgia
Vaccinated:2021-04-21
Onset:2021-04-22
Submitted:0000-00-00
Entered:2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0071321A / 2 - / -

Administered by: Private      Purchased by: ??
Symptoms: Body temperature increased, Chest pain, Fall, Gait inability, Headache, Malaise, Nausea, Rhabdomyolysis, Vomiting, Laboratory test, Oropharyngeal pain

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-29
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: FLOMAX 0.4MG DAILY IBUPROFEN AS NEEDED
Current Illness: NONE REPORTED
Preexisting Conditions: HYPERLIPIDEMIA
Allergies: NO KNOWN DRUG ALLERGIES REPORTED REPORTED
Diagnostic Lab Data: LAB TESTING AT MLMC DURING ER AND OBS STAY 04/24-04/26/2021 AND 04/27/2021-04/28/2021
CDC 'Split Type':

Write-up: SPOUSE REPORTS THE FOLLOWING FOR PATIENT 4/21/2021 @ 9PM GENERAL MALAISE 4/22/2021 APPROX 4AM SEVERE HEADACHE TOOK IBUPROFEN 4/23/2021 AFTER LUNCH, PATIENT WAS UNABLE TO WALK AS PREVIOUS AND HAD 4 FALLS, ALSO COMPLAINED OF A SORE THROAT. 4/24/2021 DID NOT FEEL WELL, TEMP UP TO 100.4, NAUSEA AND VOMITTING X 1 AND CHEST PAIN, CALLED EMS AND WAS TRANSPORTED TO MEDICAL CENTER ER. 4/26/2021 PATIENT WAS DISCHAGED HOME AFTER TREATMENT FOR RHABDOMYOLYSIS AND RETURNED TO THE HOSTPITAL AGAIN ON 04/27/2021 WITH RHABDOMYOLYSIS AS PRIMARY DIAGNSOSIS. RESIDENT DISCHARGED TO SNF ON 04/28/2021.

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