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This is VAERS ID 998576

History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 998576
VAERS Form:2
Age:86.0
Sex:Male
Location:Washington
Vaccinated:2021-01-27
Onset:2021-01-27
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, Chest X-ray abnormal, Electrocardiogram abnormal, Full blood count normal, Blood urine present, Pleural effusion, Pulmonary oedema, Pyrexia, Respiratory distress, Sinus tachycardia, Urine analysis, Protein urine present, Brain natriuretic peptide increased, Cardiac telemetry, Troponin increased, Metabolic function test, Influenza A virus test negative, Influenza virus test negative, Influenza B virus test, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-31
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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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