National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 4/23/2021 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 1228448

Government Disclaimer on use of this data



Case Details

VAERS ID: 1228448 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Kentucky  
Vaccinated:2021-04-08
Onset:2021-04-09
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 021B21A / 2 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Cardiac arrest, Death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: 1. CITALOPRAM 2. FLUTICASONE 3. MOMETASONE 4. LANSOPRAZOLE 5. NIACIN 6. EZETIMIBE 7. RANOLAZINE 8. ROSUVASTATIN 9. MONTELUKAST 10. LANTUS 11. REGULAR INSULIN 12. ELIQUIS 13. COREG 14. ENTRESTO 15. BRILINTA
Current Illness: Was admitted to hospital records 4/5 to 4/7 with c/o chest pain and GI bleed. Hgb was 6.7. Received 2 units of packed red clood cells.
Preexisting Conditions: History of COPD and Emphysema, type 2 diabetes, CKD stage 2, atrial fib, hypertension, CVA, and seizure disorder.
Allergies: NONE
Diagnostic Lab Data:
CDC Split Type:

Write-up: Received vaccine 04/08/2021. Was admitted to the hospital later in the day with cardiac arrest. Deceased 4/9/2021


New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210423&IDNUMBER=1228448


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