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This is VAERS ID 1073225

History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1073225
VAERS Form:2
Age:73.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-02
Onset:2021-02-22
Submitted:0000-00-00
Entered:2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Ascites, Asthenia, Bacteraemia, Condition aggravated, Death, Fall, Hip fracture, Hypotension, Sepsis, Tachycardia, Hip surgery, Catheter site haemorrhage, Haemorrhage, Complication associated with device

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-22
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? No
Previous Vaccinations:
Other Medications: Tylenol with codeine, albuterol, aspirin, cetirizine, dialyvite, dilaudid, fluticasone, furosemide, multivitamin, glucosamine, lactulose, lantus, nystatin, omeprazole, spironolactone, tramadol, vitamin e, xifaxan
Current Illness: Chronic Illness with debilitation
Preexisting Conditions: chronic hyponatremia, chronic low back pain, ascites, cirrhosis of liver, non-alcoholic fatty liver, dyslipidemia, diabetes, esophageal varisces. obstructive sleep apnea
Allergies: NSAIDS
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death within 30 days: Admit 2/8/21-2/13/21 s/p fall with left hip fracture (repaired), severe debility with recurrent falls discharged to SNF. Not doing well postop at the SNF, brought to ED due to failed foley insertion with bright red blood upon arrival to ER febrile, hypotensive, tachycardic, severe sepsis. Gran negative bacteremia likely from chronic ascites, family decided on comfort care and he expired within hours of admission.


Changed on 5/7/2021

VAERS ID: 1073225 Before After
VAERS Form:2
Age:73.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-02
Onset:2021-02-22
Submitted:0000-00-00
Entered:2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Ascites, Asthenia, Bacteraemia, Condition aggravated, Death, Fall, Hip fracture, Hypotension, Sepsis, Tachycardia, Hip surgery, Catheter site haemorrhage, Haemorrhage, Complication associated with device

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-22
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? No
Previous Vaccinations:
Other Medications: Tylenol with codeine, albuterol, aspirin, cetirizine, dialyvite, dilaudid, fluticasone, furosemide, multivitamin, glucosamine, lactulose, lantus, nystatin, omeprazole, spironolactone, tramadol, vitamin e, xifaxan
Current Illness: Chronic Illness with debilitation
Preexisting Conditions: chronic hyponatremia, chronic low back pain, ascites, cirrhosis of liver, non-alcoholic fatty liver, dyslipidemia, diabetes, esophageal varisces. obstructive sleep apnea
Allergies: NSAIDS NSAIDS
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death within 30 days: Admit 2/8/21-2/13/21 s/p fall with left hip fracture (repaired), severe debility with recurrent falls discharged to SNF. Not doing well postop at the SNF, brought to ED due to failed foley insertion with bright red blood upon arrival to ER febrile, hypotensive, tachycardic, severe sepsis. Gran negative bacteremia likely from chronic ascites, family decided on comfort care and he expired within hours of admission.


Changed on 5/14/2021

VAERS ID: 1073225 Before After
VAERS Form:2
Age:73.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-02
Onset:2021-02-22
Submitted:0000-00-00
Entered:2021-03-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012M20A / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Ascites, Asthenia, Bacteraemia, Condition aggravated, Death, Fall, Hip fracture, Hypotension, Sepsis, Tachycardia, Hip surgery, Catheter site haemorrhage, Haemorrhage, Complication associated with device

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-22
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? No
Previous Vaccinations:
Other Medications: Tylenol with codeine, albuterol, aspirin, cetirizine, dialyvite, dilaudid, fluticasone, furosemide, multivitamin, glucosamine, lactulose, lantus, nystatin, omeprazole, spironolactone, tramadol, vitamin e, xifaxan
Current Illness: Chronic Illness with debilitation
Preexisting Conditions: chronic hyponatremia, chronic low back pain, ascites, cirrhosis of liver, non-alcoholic fatty liver, dyslipidemia, diabetes, esophageal varisces. obstructive sleep apnea
Allergies: NSAIDS NSAIDS
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Death within 30 days: Admit 2/8/21-2/13/21 s/p fall with left hip fracture (repaired), severe debility with recurrent falls discharged to SNF. Not doing well postop at the SNF, brought to ED due to failed foley insertion with bright red blood upon arrival to ER febrile, hypotensive, tachycardic, severe sepsis. Gran negative bacteremia likely from chronic ascites, family decided on comfort care and he expired within hours of admission.

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