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From the 10/15/2021 release of VAERS data:

This is VAERS ID 998576



Case Details

VAERS ID: 998576 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Washington  
Vaccinated:2021-01-27
Onset:2021-01-27
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 042L20A / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Atelectasis, Blood creatinine increased, Blood culture negative, Blood potassium increased, Blood urine present, Brain natriuretic peptide increased, Cardiac telemetry, Chest X-ray abnormal, Electrocardiogram abnormal, Full blood count normal, Influenza A virus test negative, Influenza B virus test, Influenza virus test negative, Metabolic function test, Pleural effusion, Protein urine present, Pulmonary oedema, Pyrexia, Respiratory distress, SARS-CoV-2 test negative, Sinus tachycardia, Troponin increased, Urine analysis
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (narrow), Proteinuria (narrow), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-31
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Med List @ time vaccine # 2: PRN acetaminophen Bisacodyl PRN TUMS Clotrimazole Flonase Loratadine Lorazepam Melatonin Bengay Nitrostat Zofran oxycodone Miralax Scheduled: acetaminophen 500 md QID amlodipine 5mg BID Metoprolol 50 mg BID Pra
Current Illness: NSTEMI after COVID vaccine #1
Preexisting Conditions: CAD, CKD4, Hypertension, Anemia, dementia
Allergies: DIPYRIDAMOLE, ERYTHROMYCIN, TERAZOSIN
Diagnostic Lab Data: 1/1/2021 CMP remarkable for Potassium 5.8, creatinine 3.20, HS troponin 2.2, 310 BNP 12.7, CBC unremarkable, UA++ protein 1+ blood, Blood Cx No growth x5 days, COVID RNA rapid (-), 1/2/21 COVID PCR (-), Influenza A+B (-), No EKG, Partial CXR no acute cardio pulmonary process, no pneumonia, Telemetry Strip (12/31 22:00 atrial fib normal rate. 1/27/21 CMP remarkable for potassium 6.1, Serum Creatinine 4.46, BNP 1080, HS troponin 13.2, CBC with diff unremarkable, COVID PCR (-), EKG sinus tachycardia, QRS algorithm, left axis deviation rate 107 borderline criteria arterial infarct, CXR Bilateral + alveolar opacities compatible with pulmonary edema, small (L) pleural effusion, (L) basilar air space likely atelectasis
CDC Split Type:

Write-up: Had acute respiratory failure, dysuria NSTEMI after Dose #1 Lot # 025L20A (Moderna) hospitalized same day 12/31/20 administered @ 1040 back to baseline. 2nd Dose on 1/27/21 0950 Lot as above. Unknown exact onset same day, ED by EMS @ 1745, respiratory distress, febrile 39.4 degrees C BP 150/105 RR 29


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