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This is VAERS ID 908119

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History of Changes from the VAERS Wayback Machine

First Appeared on 12/30/2020

VAERS ID: 908119
VAERS Form:2
Age:61.0
Sex:Male
Location:Missouri
Vaccinated:2020-12-22
Onset:2020-12-23
Submitted:0000-00-00
Entered:2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Pyrexia, Vomiting, Mental status changes

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol, Atorvastatin, Bisacodyl, Calcium Acetate, Clopidogrel Bisulfate, diphenhydramine, Docusate, Levothyroxine, Midodrine, Morphine Sulfate, Oxycodone, Omeprazole, Pregabalin, Salicyic Acid gel, Senna, Simethicone, Vitamin B, Vitamin D,
Current Illness: Polyneuropathy, Sleep Apnea, Reflux, End Stage Renal disease, Anemia, Thrombocytopenia, Hypothyroidism, Type 2 Diabetes, Hyperlipidemia, Retinopathy, Hypotension, Cellulitis, Peripheral Vascular Disease, Acquired absence of kidney, Dependence on renal dialysis, Acquired absence of leg below knee. Recent mrsa infected wound, finished vancomycin on 12/18
Preexisting Conditions: See above.
Allergies: None
Diagnostic Lab Data: Started on Vancomycin in case it''s related to infected wound which is a reoccurring problem with this individual. Also started on Phenergan.
CDC 'Split Type':

Write-up: Fever 101.8, vomiting, mental status change


Changed on 5/7/2021

VAERS ID: 908119 Before After
VAERS Form:2
Age:61.0
Sex:Male
Location:Missouri
Vaccinated:2020-12-22
Onset:2020-12-23
Submitted:0000-00-00
Entered:2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Pyrexia, Vomiting, Mental status changes

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol, Atorvastatin, Bisacodyl, Calcium Acetate, Clopidogrel Bisulfate, diphenhydramine, Docusate, Levothyroxine, Midodrine, Morphine Sulfate, Oxycodone, Omeprazole, Pregabalin, Salicyic Acid gel, Senna, Simethicone, Vitamin B, Vitamin D,
Current Illness: Polyneuropathy, Sleep Apnea, Reflux, End Stage Renal disease, Anemia, Thrombocytopenia, Hypothyroidism, Type 2 Diabetes, Hyperlipidemia, Retinopathy, Hypotension, Cellulitis, Peripheral Vascular Disease, Acquired absence of kidney, Dependence on renal dialysis, Acquired absence of leg below knee. Recent mrsa infected wound, finished vancomycin on 12/18
Preexisting Conditions: See above.
Allergies: None None
Diagnostic Lab Data: Started on Vancomycin in case it''s related to infected wound which is a reoccurring problem with this individual. Also started on Phenergan.
CDC 'Split Type':

Write-up: Fever 101.8, vomiting, mental status change


Changed on 5/21/2021

VAERS ID: 908119 Before After
VAERS Form:2
Age:61.0
Sex:Male
Location:Missouri
Vaccinated:2020-12-22
Onset:2020-12-23
Submitted:0000-00-00
Entered:2020-12-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20-2A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Pyrexia, Vomiting, Mental status changes

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol, Atorvastatin, Bisacodyl, Calcium Acetate, Clopidogrel Bisulfate, diphenhydramine, Docusate, Levothyroxine, Midodrine, Morphine Sulfate, Oxycodone, Omeprazole, Pregabalin, Salicyic Acid gel, Senna, Simethicone, Vitamin B, Vitamin D,
Current Illness: Polyneuropathy, Sleep Apnea, Reflux, End Stage Renal disease, Anemia, Thrombocytopenia, Hypothyroidism, Type 2 Diabetes, Hyperlipidemia, Retinopathy, Hypotension, Cellulitis, Peripheral Vascular Disease, Acquired absence of kidney, Dependence on renal dialysis, Acquired absence of leg below knee. Recent mrsa infected wound, finished vancomycin on 12/18
Preexisting Conditions: See above.
Allergies: None None
Diagnostic Lab Data: Started on Vancomycin in case it''s related to infected wound which is a reoccurring problem with this individual. Also started on Phenergan.
CDC 'Split Type':

Write-up: Fever 101.8, vomiting, mental status change

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