| VAERS ID: |
1075657 (history) |
| Form: |
Version 2.0 |
| Age: |
94.0 |
| Sex: |
Female |
| Location: |
Wisconsin |
| Vaccinated: | 2021-03-01 |
| Onset: | 2021-03-01 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-03-05 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
043L20A / 2 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Back pain,
Condition aggravated,
Death
SMQs:, Retroperitoneal fibrosis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-04
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol 650MG BID, Eliquis 2.5MG BID, Furosemide 20MG BID, Morphine 5MG every 2 hours as needed, Potassium Chloride 10 mEq daily, Spironolactone 12.5MG daily, Zolpidem 5MG daily
Current Illness: Currently on Hospice
Preexisting Conditions: Personal history of COVID-19, Acute combined systolic (congestive) and diastolic (congestive) heart failure, Other specified diseases of liver, Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity, Other pulmonary embolism without acute cor pulmonale, Cardiomyopathy, unspecified, Coronary angioplasty status, Essential (primary) hypertension, Hyperlipidemia, unspecified, Age-related osteoporosis without current pathological fracture, Edema, unspecified, Chronic kidney disease, stage 3 (moderate), Anemia, unspecified Note: Acute chronic, Constipation, unspecified, Unspecified fracture of shaft of right fibula, initial encounter for closed fracture, Unspecified sensorineural hearing loss, Syncope and collapse, Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture, Zoster without complications (History of), Acute respiratory failure with hypoxia, Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, Peripheral vascular disease, unspecified, Cerebrovascular disease, unspecified Nonrheumatic aortic (valve) stenosis Atherosclerotic heart disease of native coronary artery without angina pectoris Nonrheumatic aortic (valve) insufficiency Alzheimer''s disease, unspecified
Allergies: Penicillin
Diagnostic Lab Data: Death on 03/04/2020 but was on Hospice
CDC Split Type:
Write-up: Resident was having back pain but did have previous back pain prior too. |
