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This is VAERS ID 935350

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/15/2021

VAERS ID: 935350
VAERS Form:2
Age:81.0
Sex:Male
Location:Texas
Vaccinated:2020-12-31
Onset:2021-01-02
Submitted:0000-00-00
Entered:2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-06
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Symbicort 160/4.5 mcg/act inhaler Dilitiazem ER 360mg PO daily Eliquis 5mg PO twice a day Furosemide 20mg PO daily Losartan 100mg PO daily KCL 10mEq ER PO daily Ranitidine 150mg PO Ventolin HFA 0.09mg/1ACT 2 puffs every 4 hours as needed Me
Current Illness: Dyspnea, Shortness of breath
Preexisting Conditions: Paroxysmal atrial fibrillation Hypertension Chronic iron deficiency anemia Congestive heart failure with chronic diastolic
Allergies: No known allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found unresponsive at home with SpO2 20% 1/2/2021


Changed on 5/7/2021

VAERS ID: 935350 Before After
VAERS Form:2
Age:81.0
Sex:Male
Location:Texas
Vaccinated:2020-12-31
Onset:2021-01-02
Submitted:0000-00-00
Entered:2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-06
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Symbicort 160/4.5 mcg/act inhaler Dilitiazem ER 360mg PO daily Eliquis 5mg PO twice a day Furosemide 20mg PO daily Losartan 100mg PO daily KCL 10mEq ER PO daily Ranitidine 150mg PO Ventolin HFA 0.09mg/1ACT 2 puffs every 4 hours as needed Me
Current Illness: Dyspnea, Shortness of breath
Preexisting Conditions: Paroxysmal atrial fibrillation Hypertension Chronic iron deficiency anemia Congestive heart failure with chronic diastolic
Allergies: No known allergies allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found unresponsive at home with SpO2 20% 1/2/2021


Changed on 5/14/2021

VAERS ID: 935350 Before After
VAERS Form:2
Age:81.0
Sex:Male
Location:Texas
Vaccinated:2020-12-31
Onset:2021-01-02
Submitted:0000-00-00
Entered:2021-01-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-06
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: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Symbicort 160/4.5 mcg/act inhaler Dilitiazem ER 360mg PO daily Eliquis 5mg PO twice a day Furosemide 20mg PO daily Losartan 100mg PO daily KCL 10mEq ER PO daily Ranitidine 150mg PO Ventolin HFA 0.09mg/1ACT 2 puffs every 4 hours as needed Me
Current Illness: Dyspnea, Shortness of breath
Preexisting Conditions: Paroxysmal atrial fibrillation Hypertension Chronic iron deficiency anemia Congestive heart failure with chronic diastolic
Allergies: No known allergies allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found unresponsive at home with SpO2 20% 1/2/2021

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=935350&WAYBACKHISTORY=ON


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