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This is VAERS ID 957799

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 957799
VAERS Form:2
Age:81.0
Sex:Male
Location:Virginia
Vaccinated:2021-01-14
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Confusional state, Death, Electrocardiogram, Full blood count normal, Metabolic function test, Troponin normal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-15
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: sotaloL (BETAPACE) 80 mg Tablet omeprazole (PRILOSEC) 20 mg Capsule, Delayed Release(E.C.) sevelamer carbonate (RENVELA) 800 mg Tablet polyethylene glycol 3350 (MIRALAX PO) acetaminophen (TYLENOL EXTRA STRENGTH PO) fluticasone propionate (F
Current Illness:
Preexisting Conditions: HTN AAA with endovascular stent ESRD COPD
Allergies: Lipitor
Diagnostic Lab Data: CBC - unremarkable CMP - stable known renal disease otherwise unremarkable Troponin normal EKG - non acute
CDC 'Split Type':

Write-up: Presented to Urgent Care for weakness and confusion, transferred to ED, patient had a cardiac arrest and was unable to be resuscitated


Changed on 5/7/2021

VAERS ID: 957799 Before After
VAERS Form:2
Age:81.0
Sex:Male
Location:Virginia
Vaccinated:2021-01-14
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Confusional state, Death, Electrocardiogram, Full blood count normal, Metabolic function test, Troponin normal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-15
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: sotaloL (BETAPACE) 80 mg Tablet omeprazole (PRILOSEC) 20 mg Capsule, Delayed Release(E.C.) sevelamer carbonate (RENVELA) 800 mg Tablet polyethylene glycol 3350 (MIRALAX PO) acetaminophen (TYLENOL EXTRA STRENGTH PO) fluticasone propionate (F
Current Illness:
Preexisting Conditions: HTN AAA with endovascular stent ESRD COPD
Allergies: Lipitor Lipitor
Diagnostic Lab Data: CBC - unremarkable CMP - stable known renal disease otherwise unremarkable Troponin normal EKG - non acute
CDC 'Split Type':

Write-up: Presented to Urgent Care for weakness and confusion, transferred to ED, patient had a cardiac arrest and was unable to be resuscitated


Changed on 5/21/2021

VAERS ID: 957799 Before After
VAERS Form:2
Age:81.0
Sex:Male
Location:Virginia
Vaccinated:2021-01-14
Onset:2021-01-15
Submitted:0000-00-00
Entered:2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Asthenia, Cardiac arrest, Confusional state, Death, Electrocardiogram, Full blood count normal, Metabolic function test, Troponin normal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-15
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:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: sotaloL (BETAPACE) 80 mg Tablet omeprazole (PRILOSEC) 20 mg Capsule, Delayed Release(E.C.) sevelamer carbonate (RENVELA) 800 mg Tablet polyethylene glycol 3350 (MIRALAX PO) acetaminophen (TYLENOL EXTRA STRENGTH PO) fluticasone propionate (F
Current Illness:
Preexisting Conditions: HTN AAA with endovascular stent ESRD COPD
Allergies: Lipitor Lipitor
Diagnostic Lab Data: CBC - unremarkable CMP - stable known renal disease otherwise unremarkable Troponin normal EKG - non acute
CDC 'Split Type':

Write-up: Presented to Urgent Care for weakness and confusion, transferred to ED, patient had a cardiac arrest and was unable to be resuscitated

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