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From the 4/30/2021 release of VAERS data:

This is VAERS ID 985814



Case Details

VAERS ID: 985814 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Male  
Location: Ohio  
Vaccinated:2021-01-20
Onset:2021-01-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 LA / IM

Administered by: Public       Purchased by: ?
Symptoms: Aspiration, Asthenia, Blood creatinine increased, Blood glucose normal, Blood potassium increased, Blood urea increased, Chest X-ray abnormal, Computerised tomogram thorax abnormal, Cough, Dyspnoea, Echocardiogram abnormal, Ejection fraction decreased, Emphysema, Endotracheal intubation, Fatigue, Haematocrit decreased, Haemoglobin decreased, Left atrial dilatation, Lung consolidation, Lung opacity, Nausea, Oropharyngeal pain, Pulmonary granuloma, Pulmonary hilum mass, Pulmonary mass, Red blood cell count decreased, Respiratory tract congestion, SARS-CoV-2 test negative, Vomiting, White blood cell count decreased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Angioedema (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haemorrhage laboratory terms (broad), Interstitial lung disease (narrow), Systemic lupus erythematosus (broad), Retroperitoneal fibrosis (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-26
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: acetaminophen 500 mg amoxicillin 1 gm aspirin furosemids 40 mg glucosamine-chondroitin 1 tab cozaar 25 mg multivitamin potassium chloride 20 meq tamsulosin 0.4 mg furosemide 40 mg zofran 4 mg
Current Illness: started with a sore throat the day before vaccination
Preexisting Conditions: anemia, BPH with obstruction, cervical neuritis, cervical spondylosis, cervicalgia, enlarged prostate, HLD, HTN, left sciatic nerve pain, low back pain, lumbar spinal stenosis, osteoarthritis, pacemaker, pancytopenia
Allergies: morphine, oxycodone, hydrocodone, hydromorphone, coumadin
Diagnostic Lab Data: 1/25/21 had CBC which showed WBC at 0.1, RBC 2.52, Hgb 8.8, Hct 27.2, Chem profile done showed high potassium, high glucose of 129, elevated BUN and Creatinine. Was negative for SARS-CoV 2 on 1/25/21. CXR showed right perihilar masslike opacity which may reflect infiltrate or neoplasm. Did CT of the chest which showed bilateral upper lobe chronic emphysematous lung changes, dense right upper lobe airspace disease, left lower lobe bronchial filling defects suggesting aspiration, scattered bilateral upper lobe nodular densities, scattered left lower lobe calcified granulomas, and left hilar calcified granuloma
CDC Split Type:

Write-up: started having generalized weakness on 1/21/21, fatigued., nausea/vomiting. went to doctor on 1/25/21 with complaint of sore throat, cough, and felt congested. Went to ER on 1/25/21 with complaints of increased shortness of breath, worsening nausea and vomiting. started on oxygen for sats of 87%. admitted on 1/25/21. On 1/26/21 needed intubated, CXR showed worsening consolidative change right lung at right hilar level. Echocardiogram showed ejection fraction 35-40%, left atrium is moderately dilated.


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