| VAERS ID: |
951688 (history) |
| Form: |
Version 2.0 |
| Age: |
63.0 |
| Sex: |
Male |
| Location: |
Arkansas |
| Vaccinated: | 2021-01-02 |
| Onset: | 2021-01-17 |
| Days after vaccination: | 15 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-17 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 1 |
- / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death
SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-17
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Diclofenac Sodium Gel 1 %, Atorvastatin Calcium Tablet 40 MG, Acetaminophen Tablet 325 MG, Melatonin Tablet 3 MG, Vitamin D3 Tablet 25 MCG, Iron Tablet 325, Multivital-M Tablet, Eliquis Tablet 5 MG, metFORMIN HCl Tablet 500 MG, NIFEdipine
Current Illness: 11/25/20 Lower mid back abscess 11/4/20 toenail removal
Preexisting Conditions: CEREBRAL INFARCTION DUE TO UNSPECIFIED OCCLUSION OR STENOSIS OF LEFT MIDDLE CEREBRAL ARTERY, PRESENCE OF AUTOMATIC (IMPLANTABLE) CARDIAC DEFIBRILLATOR, UNSPECIFIED OSTEOARTHRITIS, UNSPECIFIED SITE, APHASIA, DYSPHAGIA, UNSPECIFIED, WEAKNESS, COVID-19, OTHER REDUCED MOBILITY, URINARY TRACT INFECTION, SITE NOT SPECIFIED, ABNORMAL WEIGHT LOSS, TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, VITAMIN DEFICIENCY, UNSPECIFIED, VITAMIN D DEFICIENCY, UNSPECIFIED, ANEMIA, UNSPECIFIED, CHRONIC COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE, CHRONIC KIDNEY DISEASE, STAGE 2 (MILD), ESSENTIAL (PRIMARY) HYPERTENSION, GOUT, UNSPECIFIED, INSOMNIA, UNSPECIFIED
Allergies: No Known Allergies
Diagnostic Lab Data: na
CDC Split Type:
Write-up: Resident expired 1/17/21 |
