| VAERS ID: |
1032873 (history) |
| Form: |
Version 2.0 |
| Age: |
92.0 |
| Sex: |
Male |
| Location: |
Florida |
| Vaccinated: | 2021-02-13 |
| Onset: | 2021-02-14 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-16 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
006M20A / 1 |
AR / IM |
Administered by: Pharmacy Purchased by: ? Symptoms: Chills,
Death,
Wheezing SMQs:, Anaphylactic reaction (broad), Angioedema (broad), Asthma/bronchospasm (broad), Eosinophilic pneumonia (broad), Hypersensitivity (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-15
Days after onset: 1
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Aspirin, Lipitor, Calcium, Plavix, Cardura, Finasteride, Prozac, Metoprolol, Sinemet, Januvia, Flomax, Vitamin B12, Vitamin C, Vitamin D3 Current Illness: Had Covid 19 in Dec. 2020, Tested negative at beginning of Feb. 2021. No other illness. Preexisting Conditions: Type 2 diabetes. Controlled hypertension. Allergies: NKA Diagnostic Lab Data: None CDC Split Type:
Write-up: He had rigors starting 6 pm the day after the vaccination. He was treated with one 500 mg tylenol. He had increased wheezing but did not complain of SOB. At 0400 the next morning, he died. |