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This is VAERS ID 974833

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 974833
VAERS Form:2
Age:85.0
Sex:Male
Location:North Dakota
Vaccinated:2021-01-19
Onset:2021-01-24
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Back pain, Blood culture positive, C-reactive protein increased, Cerebral haemorrhage, Chest pain, Chest X-ray, Dyspnoea, Fibrin D dimer increased, Gram stain positive, Neck pain, Pyrexia, Unresponsive to stimuli, Urine analysis, White blood cell count increased, Haematology test, Computerised tomogram thorax normal, Laboratory test, Coagulation test, Endotracheal intubation, Seizure like phenomena, Computerised tomogram head abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-25
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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: isosorbide mononitrate ER 30mg daily, allopurinol 300mg daily, aspirin 81mg daily, nitroglycerin 0.4mg PRN, rosuvastatin 10mg daily, codine/guaifenesin syrup 5lm PO Q6H PRN, fursemide 40mg BID, levothyroxine 75mg daily, metoprolol succinate
Current Illness: unknown
Preexisting Conditions: CHF, heart murmur, hyperlipidemia, hypertension, aortic valve leak, acute renal failure, history of CABG, AICD and heart stent placement
Allergies: NKA
Diagnostic Lab Data: 1/24/21 0445:hematology, chemistry, coagulation, UA, CXR, Chest CT. 1/24/21 1705: hematology, chemistry, CXR, Head CT.
CDC 'Split Type':

Write-up: 1/24/21 0445- patient presents to the ED with complaints of neck pain, chest pain, and back pain for about a week. States also feels SOB, intermittent fever with temperature 100.3 on arrival. Patient was worked up for his cardiac type symptoms, found to have elevated WBC and CRP with no explanation. D-Dimer was elevated with CT showing no sign of PE. Patient was sent home from the ED with instructions to follow up with primary care and/or return if s/s worsen. 1/24/21 1705- patient is returned to the ED via ambulance after becoming unresponsive and some seizure like activity. Patient was intubated. Head CT showed large brain bleed that was irreparable and not compatible with life. Patient was also found with positive blood cultures x2 with gram positive cocci in clusters growing after 9 hours.


Changed on 5/7/2021

VAERS ID: 974833 Before After
VAERS Form:2
Age:85.0
Sex:Male
Location:North Dakota
Vaccinated:2021-01-19
Onset:2021-01-24
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Back pain, Blood culture positive, C-reactive protein increased, Cerebral haemorrhage, Chest pain, Chest X-ray, Dyspnoea, Fibrin D dimer increased, Gram stain positive, Neck pain, Pyrexia, Unresponsive to stimuli, Urine analysis, White blood cell count increased, Haematology test, Computerised tomogram thorax normal, Laboratory test, Coagulation test, Endotracheal intubation, Seizure like phenomena, Computerised tomogram head abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-25
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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: isosorbide mononitrate ER 30mg daily, allopurinol 300mg daily, aspirin 81mg daily, nitroglycerin 0.4mg PRN, rosuvastatin 10mg daily, codine/guaifenesin syrup 5lm PO Q6H PRN, fursemide 40mg BID, levothyroxine 75mg daily, metoprolol succinate
Current Illness: unknown
Preexisting Conditions: CHF, heart murmur, hyperlipidemia, hypertension, aortic valve leak, acute renal failure, history of CABG, AICD and heart stent placement
Allergies: NKA NKA
Diagnostic Lab Data: 1/24/21 0445:hematology, chemistry, coagulation, UA, CXR, Chest CT. 1/24/21 1705: hematology, chemistry, CXR, Head CT.
CDC 'Split Type':

Write-up: 1/24/21 0445- patient presents to the ED with complaints of neck pain, chest pain, and back pain for about a week. States also feels SOB, intermittent fever with temperature 100.3 on arrival. Patient was worked up for his cardiac type symptoms, found to have elevated WBC and CRP with no explanation. D-Dimer was elevated with CT showing no sign of PE. Patient was sent home from the ED with instructions to follow up with primary care and/or return if s/s worsen. 1/24/21 1705- patient is returned to the ED via ambulance after becoming unresponsive and some seizure like activity. Patient was intubated. Head CT showed large brain bleed that was irreparable and not compatible with life. Patient was also found with positive blood cultures x2 with gram positive cocci in clusters growing after 9 hours.


Changed on 5/14/2021

VAERS ID: 974833 Before After
VAERS Form:2
Age:85.0
Sex:Male
Location:North Dakota
Vaccinated:2021-01-19
Onset:2021-01-24
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030L20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Back pain, Blood culture positive, C-reactive protein increased, Cerebral haemorrhage, Chest pain, Chest X-ray, Dyspnoea, Fibrin D dimer increased, Gram stain positive, Neck pain, Pyrexia, Unresponsive to stimuli, Urine analysis, White blood cell count increased, Haematology test, Computerised tomogram thorax normal, Laboratory test, Coagulation test, Endotracheal intubation, Seizure like phenomena, Computerised tomogram head abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-25
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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: isosorbide mononitrate ER 30mg daily, allopurinol 300mg daily, aspirin 81mg daily, nitroglycerin 0.4mg PRN, rosuvastatin 10mg daily, codine/guaifenesin syrup 5lm PO Q6H PRN, fursemide 40mg BID, levothyroxine 75mg daily, metoprolol succinate
Current Illness: unknown
Preexisting Conditions: CHF, heart murmur, hyperlipidemia, hypertension, aortic valve leak, acute renal failure, history of CABG, AICD and heart stent placement
Allergies: NKA NKA
Diagnostic Lab Data: 1/24/21 0445:hematology, chemistry, coagulation, UA, CXR, Chest CT. 1/24/21 1705: hematology, chemistry, CXR, Head CT.
CDC 'Split Type':

Write-up: 1/24/21 0445- patient presents to the ED with complaints of neck pain, chest pain, and back pain for about a week. States also feels SOB, intermittent fever with temperature 100.3 on arrival. Patient was worked up for his cardiac type symptoms, found to have elevated WBC and CRP with no explanation. D-Dimer was elevated with CT showing no sign of PE. Patient was sent home from the ED with instructions to follow up with primary care and/or return if s/s worsen. 1/24/21 1705- patient is returned to the ED via ambulance after becoming unresponsive and some seizure like activity. Patient was intubated. Head CT showed large brain bleed that was irreparable and not compatible with life. Patient was also found with positive blood cultures x2 with gram positive cocci in clusters growing after 9 hours.

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