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VAERS ID: | 921572 |
VAERS Form: | 2 |
Age: | 87.0 |
Sex: | Male |
Location: | Wisconsin |
Vaccinated: | 2020-12-29 |
Onset: | 2020-12-30 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-05 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | - / 1 | LA / IM |
Administered by: Senior Living Purchased by: ??
Symptoms: Chills, Death, Fall, Hip fracture, Oxygen saturation decreased, Pain, Unresponsive to stimuli
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-02
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? No
Previous Vaccinations:
Other Medications: Fluticasone, Lasix, Omeprazole, Sucarafate, Ropinrole HCl
Current Illness: Heart Failure
Preexisting Conditions: Chronic Kidney Disease, Atherosclerotic Heart Disease
Allergies: Lisinopril, Losartan
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: Resident had body aches, a low O2 sat and had chills starting on 12/30/20. He had stated that they had slightly improved. On 1/1/21 he sustained a fall with a diagnosis of a displaced hip fracture. On 1/2/21 during the NOC shift his O2 sat dropped again. He later went unresponsive and passed away.
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