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This is VAERS ID 1039304

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1039304
VAERS Form:2
Age:73.0
Sex:Male
Location:California
Vaccinated:2021-01-29
Onset:2021-02-02
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood sodium normal, Blood urea increased, Body temperature increased, Death, Dysphagia, Pneumonia, White blood cell count increased, Respiratory tract congestion, Gastrointestinal tube insertion, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 12     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amantadine HCl Tablet 100 MG, Fluticasone Propionate Suspension 50 MCG/AC, Metoprolol Tartrate Tablet,Rotigotine Patch 24 Hour 6 MG/24HR, Magnesium Oxide Tablet 400 MG, Heparin Sodium (Porcine) Solution 5000 UNIT/ML,Aspirin EC Tablet Delaye
Current Illness: Parkinson''s disease, S/P GT Placement, HTN, Allergic Rhinitis, Protein Calorie Malnutrition, Herpes Viral Infection, Dysphagia, S/P Pacemaker Insertion
Preexisting Conditions: End Stage Parkinson''s Disease
Allergies: Flomax
Diagnostic Lab Data: 01/31/21 Rapid Test (-) COVID 02/02/21 Rapid Test (-) COVID 02/04/21 Rapid Test (-) COVID 02/02/21- WBC 20.92, Na 142, BUN 59- MD was notified
CDC 'Split Type':

Write-up: Resident getting rehab therapy in the facility and has a long history of Parkinson''s Disease. On 01/29/21, he received the COVID vaccine on left deltoid, resident was recently hospitalized due to Pneumonia and was on antibiotic IV and was recently placed on GT feeding due to severe dysphagia from his Parkinson''s disease. On 01/31/21, started having increased congestion. On 02/02/21, started having increased temperature and WBC went up $g20,000 on 02/03/21, started on Vancomycin IV on 02/04/21 but was transferred to the hospital. Facility was notified today (02/18/21) that resident expired in the hospital.


Changed on 5/7/2021

VAERS ID: 1039304 Before After
VAERS Form:2
Age:73.0
Sex:Male
Location:California
Vaccinated:2021-01-29
Onset:2021-02-02
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood sodium normal, Blood urea increased, Body temperature increased, Death, Dysphagia, Pneumonia, White blood cell count increased, Respiratory tract congestion, Gastrointestinal tube insertion, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 12     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amantadine HCl Tablet 100 MG, Fluticasone Propionate Suspension 50 MCG/AC, Metoprolol Tartrate Tablet,Rotigotine Patch 24 Hour 6 MG/24HR, Magnesium Oxide Tablet 400 MG, Heparin Sodium (Porcine) Solution 5000 UNIT/ML,Aspirin EC Tablet Delaye
Current Illness: Parkinson''s disease, S/P GT Placement, HTN, Allergic Rhinitis, Protein Calorie Malnutrition, Herpes Viral Infection, Dysphagia, S/P Pacemaker Insertion
Preexisting Conditions: End Stage Parkinson''s Disease
Allergies: Flomax Flomax
Diagnostic Lab Data: 01/31/21 Rapid Test (-) COVID 02/02/21 Rapid Test (-) COVID 02/04/21 Rapid Test (-) COVID 02/02/21- WBC 20.92, Na 142, BUN 59- MD was notified
CDC 'Split Type':

Write-up: Resident getting rehab therapy in the facility and has a long history of Parkinson''s Disease. On 01/29/21, he received the COVID vaccine on left deltoid, resident was recently hospitalized due to Pneumonia and was on antibiotic IV and was recently placed on GT feeding due to severe dysphagia from his Parkinson''s disease. On 01/31/21, started having increased congestion. On 02/02/21, started having increased temperature and WBC went up $g20,000 on 02/03/21, started on Vancomycin IV on 02/04/21 but was transferred to the hospital. Facility was notified today (02/18/21) that resident expired in the hospital.


Changed on 5/14/2021

VAERS ID: 1039304 Before After
VAERS Form:2
Age:73.0
Sex:Male
Location:California
Vaccinated:2021-01-29
Onset:2021-02-02
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 037K20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood sodium normal, Blood urea increased, Body temperature increased, Death, Dysphagia, Pneumonia, White blood cell count increased, Respiratory tract congestion, Gastrointestinal tube insertion, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-15
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days: 12     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Amantadine HCl Tablet 100 MG, Fluticasone Propionate Suspension 50 MCG/AC, Metoprolol Tartrate Tablet,Rotigotine Patch 24 Hour 6 MG/24HR, Magnesium Oxide Tablet 400 MG, Heparin Sodium (Porcine) Solution 5000 UNIT/ML,Aspirin EC Tablet Delaye
Current Illness: Parkinson''s disease, S/P GT Placement, HTN, Allergic Rhinitis, Protein Calorie Malnutrition, Herpes Viral Infection, Dysphagia, S/P Pacemaker Insertion
Preexisting Conditions: End Stage Parkinson''s Disease
Allergies: Flomax Flomax
Diagnostic Lab Data: 01/31/21 Rapid Test (-) COVID 02/02/21 Rapid Test (-) COVID 02/04/21 Rapid Test (-) COVID 02/02/21- WBC 20.92, Na 142, BUN 59- MD was notified
CDC 'Split Type':

Write-up: Resident getting rehab therapy in the facility and has a long history of Parkinson''s Disease. On 01/29/21, he received the COVID vaccine on left deltoid, resident was recently hospitalized due to Pneumonia and was on antibiotic IV and was recently placed on GT feeding due to severe dysphagia from his Parkinson''s disease. On 01/31/21, started having increased congestion. On 02/02/21, started having increased temperature and WBC went up $g20,000 on 02/03/21, started on Vancomycin IV on 02/04/21 but was transferred to the hospital. Facility was notified today (02/18/21) that resident expired in the hospital.

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