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This is VAERS ID 924201

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 924201
VAERS Form:2
Age:94.0
Sex:Male
Location:Maryland
Vaccinated:2020-12-24
Onset:2021-01-03
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: Back pain, Catheterisation cardiac abnormal, Chest pain, Coronary artery stenosis, Electrocardiogram abnormal, Ejection fraction decreased, Acute coronary syndrome, Coronary arterial stent insertion, Troponin increased, Echocardiogram abnormal, Percutaneous coronary intervention

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 3     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


Changed on 5/7/2021

VAERS ID: 924201 Before After
VAERS Form:2
Age:94.0
Sex:Male
Location:Maryland
Vaccinated:2020-12-24
Onset:2021-01-03
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: Back pain, Catheterisation cardiac abnormal, Chest pain, Coronary artery stenosis, Electrocardiogram abnormal, Ejection fraction decreased, Acute coronary syndrome, Coronary arterial stent insertion, Troponin increased, Echocardiogram abnormal, Percutaneous coronary intervention

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 3     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) 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


Changed on 5/21/2021

VAERS ID: 924201 Before After
VAERS Form:2
Age:94.0
Sex:Male
Location:Maryland
Vaccinated:2020-12-24
Onset:2021-01-03
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: Back pain, Catheterisation cardiac abnormal, Chest pain, Coronary artery stenosis, Electrocardiogram abnormal, Ejection fraction decreased, Acute coronary syndrome, Coronary arterial stent insertion, Troponin increased, Echocardiogram abnormal, Percutaneous coronary intervention

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 3     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) 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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