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From the 1/14/2022 release of VAERS data:

This is VAERS ID 924201

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Case Details

VAERS ID: 924201 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Maryland  
Vaccinated:2020-12-24
Onset:2021-01-03
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-01-06
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK - / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute coronary syndrome, Back pain, Catheterisation cardiac abnormal, Chest pain, Coronary arterial stent insertion, Coronary artery stenosis, Echocardiogram abnormal, Ejection fraction decreased, Electrocardiogram abnormal, Percutaneous coronary intervention, Troponin increased
SMQs:, Cardiac failure (narrow), Myocardial infarction (narrow), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Embolic and thrombotic events, arterial (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (narrow), Other ischaemic heart disease (narrow)

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Prilosec 20 mg qd Lipitor 20 mg qd Levothyroxine 100 mcg/d (incr from 88 for TSH 4.78 8/26/20) Ativan 0.5-1 mg hs prn 10-15/month EC ASA 2 x 81 mg qd
Current Illness: Adjustment disorder/grief reaction
Preexisting Conditions: PAST MEDICAL HISTORY Surgical- T&A age 5 Appendectomy age 8 or 9 Rhinoplasty for deviated septum x 2 1960s Gas gangrene Right Leg- debridement 1972 Right inguinal hernia ~2002 Bilateral Cataracts/IOLs 2014 Umbilical Herniorrhaphy 2020 Medical- Hepatitis and possible malaria 1944 Hyperlipidemia GERD/Barretts- Lower GI bleed hospitalized ~1994; no Tx Hemorrhoids Anal fistula Herpes zoster Nov 2012 Left Trigeminal Hypothyroidism Dec 2013 (fatigue, elevated TSH 5.81, fT4 0.7) Childhood Diseases- Measles- yes; Mumps- yes; Rubella- ?; Varicella- yes; Rheumatic Fever- no; Pertussis- yes Habits- Tobacco- quit 1950; Alcohol- 0-2 night; Drugs- no Immunizations- Td- 3/08, 8/22/19; TdaP- ; Influenza- 8/25/20; Pneumovax- yes <2003, 3/08; PCV13- 12/19/14; Hep A- ; Hep B- ; Zostavax- 3/07; Shingrix- 2/21/18, 10/30/18; Covid 19 (Moderna) 12/24/20
Allergies: PCN- rash? Bee sting- swelling (has Epipen) (no hx food or latex allergy)
Diagnostic Lab Data: Elevated Troponin, NSST changes on ECG, Cardiac Catheterization showing 99% mid-LAD and 30-40% RCA lesions. Echocardiogram +hypokinesis of anterior wall/septum with reduced EF 45-50%
CDC Split Type:

Write-up: Patient tolerated the vaccine well with no apparent side effects. Ten days later awoke 12:30 AM with severe chest and upper back pain, presented to Med Center where he was found to have an Acute Coronary Syndrome. Transferred to Medical Center where he underwent successful PCI with two drug eluting stents for a 99% mid-LAD stenosis


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