VAERS ID: |
1020227 (history) |
Form: |
Version 2.0 |
Age: |
96.0 |
Sex: |
Male |
Location: |
New Mexico |
Vaccinated: | 2021-02-05 |
Onset: | 2021-02-07 |
Days after vaccination: | 2 |
Submitted: |
0000-00-00 |
Entered: |
2021-02-10 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
026L20A / 1 |
RA / IM |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
032L20A / 2 |
LA / IM |
Administered by: Private Purchased by: ? Symptoms: Death,
Illness,
Patient isolation,
Syncope SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-07
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: ALENDRONATE SODIUM 70MG TABLET (4''S) TAKE ONE (1) TABLET ACTIVE BY MOUTH ONE TIME EACH WEEK WITH WATER 30 MINUTES BEFORE EATING OR TAKING OTHER MEDICATIONS CALCIUM W/ VITAMIN D 600/500 SLOW RELEASE TAKE 2 TABLETS ACTIVE BY MOUT Current Illness: Pt had COVID with symptom onset 1/27/21, pos test 1/28/21 admitted to Hosptial and was treated w/ remdesivir at , discharged 1/30 on Dexamethasone 6mg daily, no need for O2 supplement. First moderna COVID vaccine was 1/5/21. Preexisting Conditions: 1)*AU SEVERE LOSS 2)Anemia - 3)Tubular adenoma of colon - 4)*SCLERAL PLAQUE EXCISION OS - STILL PO 2+ MONTH 5)Osteoarthritis - bilateral knees...worse in right knee -QUALIFIERS: Severity Moderate to severe 6)Chronic obstructive lung disease - 7)Onychomycosis - x10 -QUALIFIERS: Severity Mild to moderate Clinical course Chronic 8)Artificial lens present - OU 9)Hypermetropia - OD 10)Presbyopia - OU 11)Regular astigmatism - OD 12)Arcus of cornea - OU 13)Scarred macula - OS 14)Osteoporosis - 15)Osteoarthritis of knee - 16)Hypothyroidism - 17)Benign prostatic hyperplasia - 18)Hip pain, Right - Had right hip fracture pinning and has post traumatic DJD 19)Chronic pain - 20)Dry eyes - 21)Sensorineural hearing loss, Bilateral - 22)Nonexudative age-related macular degeneration, Bilateral - Allergies: Allergies: CODEINE Diagnostic Lab Data: None CDC Split Type:
Write-up: This is the patient who passed away 2d after his second COVID vaccine. Of note, the 2/8 telephone note makes it sound like he was hospitalized at time of death - that is incorrect. His daugther listed as EM contact works in the eye clinic here. He had mild illness, completed 10d isolation but missed his scheduled booster dose on 2/2 due to isolation. He was called on 2/5 when there was a booster visit cancellation and received his booster dose on that day. His daugther reported that he was doing fine and looking well on 2/7 AM, ate breakfast, shortly after stood up and just collapsed. |