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This is VAERS ID 1055149

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1055149
VAERS Form:2
Age:95.0
Sex:Male
Location:Michigan
Vaccinated:2021-02-16
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027LZOA / 2 - / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Dyspnoea, Respiratory distress, Wheezing, Use of accessory respiratory muscles

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-22
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: Amlodipine, lasix, toprol XL, PRN: lorazipam and morphine
Current Illness: MEDICAL HISTORY; CHF (EF=20%), CAD, AAA (NO REPAIR) 5.3CM, ANEMIA (HISTORY TRANSFUSIONS ARANESP/PROCRIT), CKD STAGE 5 (BUN=110/CREATININE=6.09), HTN, ISCHEMIC CARDIOMYOPATHY, GLAUCOMA, HOH, COVID-19 PNEUMONIA 11-27-2020 THROUGH 12-12-2020, SEVERE NONRHEUMATIC MITRAL VALVE REGURGITATION, NSTEMI 03-27-2019, CAROTID ARTERY STENOSIS, CABG 2009, CARDIAC STENT PLACEMENT, FORMER SMOKER.
Preexisting Conditions: see above
Allergies: ace inhibitors, codeine, lysynopril
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: This is a hospice patient under the care of Hospice at an affiliated nursing home. Pt received the vaccination around noon on 2-16-21 by a representative from Pharmacy. The following afternoon 2-17-21 at 14:45 the pt started to experience severe SOB resp rate 36, audible wheezing and use of respiratory accessory muscles. BP180/80, 113 pulse temp 98. Pt was given morphine and ativan. The respiratory distress was eased however pt never returned to baseline and died 2-22-21 around 4am.


Changed on 5/7/2021

VAERS ID: 1055149 Before After
VAERS Form:2
Age:95.0
Sex:Male
Location:Michigan
Vaccinated:2021-02-16
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027LZOA / 2 - / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Dyspnoea, Respiratory distress, Wheezing, Use of accessory respiratory muscles

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-22
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: Amlodipine, lasix, toprol XL, PRN: lorazipam and morphine
Current Illness: MEDICAL HISTORY; CHF (EF=20%), CAD, AAA (NO REPAIR) 5.3CM, ANEMIA (HISTORY TRANSFUSIONS ARANESP/PROCRIT), CKD STAGE 5 (BUN=110/CREATININE=6.09), HTN, ISCHEMIC CARDIOMYOPATHY, GLAUCOMA, HOH, COVID-19 PNEUMONIA 11-27-2020 THROUGH 12-12-2020, SEVERE NONRHEUMATIC MITRAL VALVE REGURGITATION, NSTEMI 03-27-2019, CAROTID ARTERY STENOSIS, CABG 2009, CARDIAC STENT PLACEMENT, FORMER SMOKER.
Preexisting Conditions: see above
Allergies: ace inhibitors, codeine, lysynopril lysynopril
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: This is a hospice patient under the care of Hospice at an affiliated nursing home. Pt received the vaccination around noon on 2-16-21 by a representative from Pharmacy. The following afternoon 2-17-21 at 14:45 the pt started to experience severe SOB resp rate 36, audible wheezing and use of respiratory accessory muscles. BP180/80, 113 pulse temp 98. Pt was given morphine and ativan. The respiratory distress was eased however pt never returned to baseline and died 2-22-21 around 4am.


Changed on 5/14/2021

VAERS ID: 1055149 Before After
VAERS Form:2
Age:95.0
Sex:Male
Location:Michigan
Vaccinated:2021-02-16
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027LZOA / 2 - / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Dyspnoea, Respiratory distress, Wheezing, Use of accessory respiratory muscles

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-22
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: Amlodipine, lasix, toprol XL, PRN: lorazipam and morphine
Current Illness: MEDICAL HISTORY; CHF (EF=20%), CAD, AAA (NO REPAIR) 5.3CM, ANEMIA (HISTORY TRANSFUSIONS ARANESP/PROCRIT), CKD STAGE 5 (BUN=110/CREATININE=6.09), HTN, ISCHEMIC CARDIOMYOPATHY, GLAUCOMA, HOH, COVID-19 PNEUMONIA 11-27-2020 THROUGH 12-12-2020, SEVERE NONRHEUMATIC MITRAL VALVE REGURGITATION, NSTEMI 03-27-2019, CAROTID ARTERY STENOSIS, CABG 2009, CARDIAC STENT PLACEMENT, FORMER SMOKER.
Preexisting Conditions: see above
Allergies: ace inhibitors, codeine, lysynopril lysynopril
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: This is a hospice patient under the care of Hospice at an affiliated nursing home. Pt received the vaccination around noon on 2-16-21 by a representative from Pharmacy. The following afternoon 2-17-21 at 14:45 the pt started to experience severe SOB resp rate 36, audible wheezing and use of respiratory accessory muscles. BP180/80, 113 pulse temp 98. Pt was given morphine and ativan. The respiratory distress was eased however pt never returned to baseline and died 2-22-21 around 4am.

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