Adverse Event Reporting

VAERS ID 1736686
Gender Male
Age 83
StateCode MI
Pharmaceutical Company MODERNA
Lot Number 003B21A
Number of vaccinations 2
Vaccinated 2021-03-18
Onset 2021-09-18
Condition Hospitalized
  • Oropharyngeal pain
  • Cough
  • SARS-CoV-2 test positive
  • COVID-19

Current Illness

None known

Preexisting Conditions

Allergy to environmental factors Gout without tophus ST elevation myocardial infarction (STEMI), unspecified artery Hyperlipemia ASHD (arteriosclerotic heart disease) CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min Angina pectoris

Other Medications

allopurinol (ZYLOPRIM) 300 MG tablet aspirin low dose 81 MG chew tablet atorvastatin (LIPITOR) 10 MG tablet carvedilol (COREG) 6.25 MG tablet diphenhydrAMINE (BENADRYL) 25 MG capsule loratadine (CLARITIN) 10 MG tablet multivitamin/beta caro

Previous Vaccinations


Ramipril (swelling)

Laboratory Data

COVID-19 test positive on 9/18/2021.


Patient presented to emergency department on 9/18/2021 with a sore throat and dry cough.
He was found to be COVID-19 positive and was admitted for further management.
Patient was treated with dexamethasone.
He was discharged home on 9/26/2021.