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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 910363 |
VAERS Form: | 2 |
Age: | 84.0 |
Sex: | Male |
Location: | California |
Vaccinated: | 2020-12-23 |
Onset: | 2020-12-26 |
Submitted: | 0000-00-00 |
Entered: | 2020-12-28 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | LOT 039K20A / 1 | RA / IM |
Administered by: Senior Living Purchased by: ??
Symptoms: Death, Hypotension, Somnolence, Hypophagia
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2020-12-28
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? No
Previous Vaccinations:
Other Medications: risperidone daily doxazosin
Current Illness: dementia declining oral intake
Preexisting Conditions: history of aspiration pneumonia BPH
Allergies: none
Diagnostic Lab Data: none
CDC 'Split Type':
Write-up: Patient had mild hypotension, decreased oral intake, somnolence starting 3 days after vaccination and death 5 days after administration. He did have advanced dementia and was hospice eligible based on history of aspiration pneumonia.
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