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History of Changes from the VAERS Wayback Machine |
VAERS ID: | 947662 |
VAERS Form: | 2 |
Age: | 84.0 |
Sex: | Male |
Location: | Minnesota |
Vaccinated: | 2020-12-30 |
Onset: | 2021-01-01 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-15 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA | 037K20A / 1 | RA / IM |
Administered by: Senior Living Purchased by: ??
Symptoms: Death, Somnolence, General physical health deterioration, Hypophagia, Hyporesponsive to stimuli
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Terazosin 5mg po HS, Metoprolol 12.5 mg BID, Depakote 375mg BID, Hydrochlorothiazide 12.5mg Q am
Current Illness: no acute illnesses
Preexisting Conditions: Alzheimers, Dementia without behaviors, Chronic Venous hypertension, Aphasia, Benign Prostatic Hypertrophy, Aphasia, Osteoarthritis
Allergies: Lisinopril
Diagnostic Lab Data: None completed- Resident was determined to be at end of life
CDC 'Split Type':
Write-up: Accelerated decline in condition with decreased input, decreased responsiveness, somnolence, and death
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