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This is VAERS ID 1273626

History of Changes from the VAERS Wayback Machine

First Appeared on 5/7/2021

VAERS ID: 1273626
VAERS Form:2
Age:60.0
Sex:Male
Location:Florida
Vaccinated:2021-03-22
Onset:2021-03-28
Submitted:0000-00-00
Entered:2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Acute respiratory distress syndrome, Death, Hypertension, Intensive care, Bed rest, Mechanical ventilation, Endotracheal intubation, Type 2 diabetes mellitus, Multiple organ dysfunction syndrome, COVID-19, SARS-CoV-2 test positive, COVID-19 pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-22
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt developed symptoms of COVID-19 and was placed on bedrest on 03/28/2021. The patient was sent to local ED on 04/01/2021 and then tested for COVID-19 with a positive result. Patient was intubated and placed on ventilator. Pt. spent 22 days in ICU. Pt expired on 04/22/2021 with cause of death listed as MODS and COVID-19 related PNA. Related causes of death were listed as HTN, DMII, and ARDS.


Changed on 5/14/2021

VAERS ID: 1273626 Before After
VAERS Form:2
Age:60.0
Sex:Male
Location:Florida
Vaccinated:2021-03-22
Onset:2021-03-28
Submitted:0000-00-00
Entered:2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007B21A / 1 LA / IM

Administered by: Public      Purchased by: ??
Symptoms: Acute respiratory distress syndrome, Death, Hypertension, Intensive care, Bed rest, Mechanical ventilation, Endotracheal intubation, Type 2 diabetes mellitus, Multiple organ dysfunction syndrome, COVID-19, SARS-CoV-2 test positive, COVID-19 pneumonia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-22
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:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt developed symptoms of COVID-19 and was placed on bedrest on 03/28/2021. The patient was sent to local ED on 04/01/2021 and then tested for COVID-19 with a positive result. Patient was intubated and placed on ventilator. Pt. spent 22 days in ICU. Pt expired on 04/22/2021 with cause of death listed as MODS and COVID-19 related PNA. Related causes of death were listed as HTN, DMII, and ARDS.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1273626&WAYBACKHISTORY=ON

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