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This is VAERS ID 1689325

History of Changes from the VAERS Wayback Machine

First Appeared on 9/17/2021

VAERS ID: 1689325
VAERS Form:2
Age:88.0
Sex:Male
Location:Texas
Vaccinated:2021-02-12
Onset:2021-08-18
Submitted:0000-00-00
Entered:2021-09-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Blood creatine increased, C-reactive protein increased, Chest X-ray abnormal, Confusional state, Crystal urine present, Death, Blood urine present, Incontinence, Oxygen saturation decreased, Pollakiuria, Pyrexia, Respiratory failure, Tachypnoea, Urine abnormality, White blood cell count increased, Protein urine present, Lung opacity, Nucleic acid test, COVID-19, SARS-CoV-2 test positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-08-28
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: 10     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allopurinol 300mg BID, Ocuvite Extra daily, apixaban 5mg BID, azithromycin 250mg 2 tab on day 1 and 1 tab daily after, Lumigan 0.01% 1 drop both eyes nightly, Alphagan 0.1% 1 drop in right eye BID, calcium-vitamin D 500mg-200unit BID, clopi
Current Illness: TAVR July 2021
Preexisting Conditions: CAD s/p CABG, CHF, severe aortic stenosis, Afib, HTN, CKD, hypothyroid, arthritis, Hx of chronic lymphocytic leukemia, DM, dyslipidemia, gout
Allergies: Ciprofloxacin
Diagnostic Lab Data: COVID-19 Positive 8/18/21 This sample was analyzed using the Roche LIAT SARS assay platform using PCR or equivalent Nucleic Acid Amplification (NAA) technology.
CDC 'Split Type':

Write-up: Moderna COVID-19 Vaccine EUA: COVID-19 case resulting in Hospitalization / Death. Patient received Moderna Vaccine on 1/14/2021 and 2/12/2021. Presented to ED on 8/18/21. Family was concerned about patient''s increasing confusion and generalized weakness, urinary frequency, incontinence, and fever. In the ED, the patient was found to have WBC count 16.9, Cr 1.38, urine is hazy with amorphous crystals, blood pos 1+, trace protein, CRP 11.3, Cr 1.38 which was up from 0.8 from July 2021, CT chest shows ground glass opacities in bilateral lungs. Patient was experiencing respiratory failure and was placed on Airvo at 80%. He experienced low saturations in low 80s and was tachypneic in 40s. Patient voiced he did not want to be intubated. Patient received Solumedrol, Ceftriaxone, Doxycycline, Remdesivir. Pt removed his oxygen and restated he did not want it. The patient expired on 8/28/21.

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