National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 958228

History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 958228
VAERS Form:2
Age:83.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-12
Onset:2021-01-18
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0329K20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase normal, Blood albumin decreased, Blood bilirubin normal, Blood calcium normal, Blood chloride increased, Blood creatinine increased, Blood glucose increased, Blood potassium increased, Blood sodium increased, Blood urea increased, Carbon dioxide decreased, Death, Diet refusal, Hypernatraemia, Protein total normal, Blood alkaline phosphatase increased, Metabolic function test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-18
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: 1) AMLODIPINE BESYLATE TAB 5MG PO QPM ACTIVE 2) ASPIRIN (OTC) TAB,CHEWABLE 81MG PO QDAILY ACTIVE 3) CARVEDILOL TAB 12.5MG PO BID ACTIVE 4) CHOLECALCIFEROL (VIT D3) 25MCG=100
Current Illness: none other than chronic conditions as listed under item 12.
Preexisting Conditions: acute on chronic kidney failure, Alzheimer''s dementia, diabetes mellitus type II, hypothyroidism, bipolar disorder, hypertension, hyperlipidemia
Allergies: Niacin - rash
Diagnostic Lab Data: Collection time: Jan 17, 2021@06:00 Test Name Result Units Range --------- ------ ----- ----- GLUCOSE 166H mg/dL 70 - 99 UREA NITROGEN 138H mg/dL 7 - 18 CREATININE 6.93H mg/dL .7 - 1.3 SODIUM 165H* mmol/L 136 - 145 POTASSIUM 5.2H mmol/L 3.5 - 5.1 CHLORIDE 130H mmol/L 98 - 107 CO2 21 mmol/L 21 - 32 CALCIUM, TOTAL 9.2 mg/dL 8.5 - 10.1 PROTEIN, TOTL 7.8 g/dL 6.4 - 8.2 ALBUMIN 3.2L g/dL 3.4 - 5.0 AST 16 U/L 15 - 37 ALT 22 U/L 16 - 63 BILI,TOTAL 0.3 mg/dL 0.2 - 1.0 ALKAL PHOS 168H U/L 46 - 116 EGFR canc ANION GAP 20.0 mmol/L 10 - 20
CDC 'Split Type':

Write-up: Patient has end stage renal disease and rapidly worsening dementia, family could no longer care for him at home, and he was admitted for 14-day quarantine prior to admission to inpatient hospice. Received vaccine on 1/12 without apparent adverse reactions. Patient started refusing oral intake on 1/16, and CMP on 1/17 showed hypernatremia 165 (new issue). His BUN 138 CREAT 6.93 K 5.2 were his baseline. He was found to be deceased on 1/18 at 11:18 pm.


Changed on 5/7/2021

VAERS ID: 958228 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-12
Onset:2021-01-18
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0329K20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase normal, Blood albumin decreased, Blood bilirubin normal, Blood calcium normal, Blood chloride increased, Blood creatinine increased, Blood glucose increased, Blood potassium increased, Blood sodium increased, Blood urea increased, Carbon dioxide decreased, Death, Diet refusal, Hypernatraemia, Protein total normal, Blood alkaline phosphatase increased, Metabolic function test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-18
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: 1) AMLODIPINE BESYLATE TAB 5MG PO QPM ACTIVE 2) ASPIRIN (OTC) TAB,CHEWABLE 81MG PO QDAILY ACTIVE 3) CARVEDILOL TAB 12.5MG PO BID ACTIVE 4) CHOLECALCIFEROL (VIT D3) 25MCG=100
Current Illness: none other than chronic conditions as listed under item 12.
Preexisting Conditions: acute on chronic kidney failure, Alzheimer''s dementia, diabetes mellitus type II, hypothyroidism, bipolar disorder, hypertension, hyperlipidemia
Allergies: Niacin - rash rash
Diagnostic Lab Data: Collection time: Jan 17, 2021@06:00 Test Name Result Units Range --------- ------ ----- ----- GLUCOSE 166H mg/dL 70 - 99 UREA NITROGEN 138H mg/dL 7 - 18 CREATININE 6.93H mg/dL .7 - 1.3 SODIUM 165H* mmol/L 136 - 145 POTASSIUM 5.2H mmol/L 3.5 - 5.1 CHLORIDE 130H mmol/L 98 - 107 CO2 21 mmol/L 21 - 32 CALCIUM, TOTAL 9.2 mg/dL 8.5 - 10.1 PROTEIN, TOTL 7.8 g/dL 6.4 - 8.2 ALBUMIN 3.2L g/dL 3.4 - 5.0 AST 16 U/L 15 - 37 ALT 22 U/L 16 - 63 BILI,TOTAL 0.3 mg/dL 0.2 - 1.0 ALKAL PHOS 168H U/L 46 - 116 EGFR canc ANION GAP 20.0 mmol/L 10 - 20
CDC 'Split Type':

Write-up: Patient has end stage renal disease and rapidly worsening dementia, family could no longer care for him at home, and he was admitted for 14-day quarantine prior to admission to inpatient hospice. Received vaccine on 1/12 without apparent adverse reactions. Patient started refusing oral intake on 1/16, and CMP on 1/17 showed hypernatremia 165 (new issue). His BUN 138 CREAT 6.93 K 5.2 were his baseline. He was found to be deceased on 1/18 at 11:18 pm.


Changed on 5/14/2021

VAERS ID: 958228 Before After
VAERS Form:2
Age:83.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-12
Onset:2021-01-18
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0329K20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase normal, Blood albumin decreased, Blood bilirubin normal, Blood calcium normal, Blood chloride increased, Blood creatinine increased, Blood glucose increased, Blood potassium increased, Blood sodium increased, Blood urea increased, Carbon dioxide decreased, Death, Diet refusal, Hypernatraemia, Protein total normal, Blood alkaline phosphatase increased, Metabolic function test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-18
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: 1) AMLODIPINE BESYLATE TAB 5MG PO QPM ACTIVE 2) ASPIRIN (OTC) TAB,CHEWABLE 81MG PO QDAILY ACTIVE 3) CARVEDILOL TAB 12.5MG PO BID ACTIVE 4) CHOLECALCIFEROL (VIT D3) 25MCG=100
Current Illness: none other than chronic conditions as listed under item 12.
Preexisting Conditions: acute on chronic kidney failure, Alzheimer''s dementia, diabetes mellitus type II, hypothyroidism, bipolar disorder, hypertension, hyperlipidemia
Allergies: Niacin - rash rash
Diagnostic Lab Data: Collection time: Jan 17, 2021@06:00 Test Name Result Units Range --------- ------ ----- ----- GLUCOSE 166H mg/dL 70 - 99 UREA NITROGEN 138H mg/dL 7 - 18 CREATININE 6.93H mg/dL .7 - 1.3 SODIUM 165H* mmol/L 136 - 145 POTASSIUM 5.2H mmol/L 3.5 - 5.1 CHLORIDE 130H mmol/L 98 - 107 CO2 21 mmol/L 21 - 32 CALCIUM, TOTAL 9.2 mg/dL 8.5 - 10.1 PROTEIN, TOTL 7.8 g/dL 6.4 - 8.2 ALBUMIN 3.2L g/dL 3.4 - 5.0 AST 16 U/L 15 - 37 ALT 22 U/L 16 - 63 BILI,TOTAL 0.3 mg/dL 0.2 - 1.0 ALKAL PHOS 168H U/L 46 - 116 EGFR canc ANION GAP 20.0 mmol/L 10 - 20
CDC 'Split Type':

Write-up: Patient has end stage renal disease and rapidly worsening dementia, family could no longer care for him at home, and he was admitted for 14-day quarantine prior to admission to inpatient hospice. Received vaccine on 1/12 without apparent adverse reactions. Patient started refusing oral intake on 1/16, and CMP on 1/17 showed hypernatremia 165 (new issue). His BUN 138 CREAT 6.93 K 5.2 were his baseline. He was found to be deceased on 1/18 at 11:18 pm.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=958228&WAYBACKHISTORY=ON

Government Disclaimer on use of this data


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166