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This is VAERS ID 1105115

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1105115
VAERS Form:2
Age:18.0
Sex:Male
Location:Puerto Rico
Vaccinated:2021-02-14
Onset:2021-02-18
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Decreased activity, Groin abscess, Abscess limb, Increased upper airway secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-28
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: Keppra 1000 mg, Lamictal , Vimpat, Quetiapina, Lorazepam, Zyprexa, Motrin, Vitamina K, Acido Folico, Sultato Ferroso, Multivitam?nico 365
Current Illness: None
Preexisting Conditions: Portal hypertension (secondary to portal vein thrombosis), Leukopenia, Thrombocytopenia, Epilepsy, Splenomegaly, Esophageal Varices, Asthma, Pancytopenia and Severe mental retardation.
Allergies: Dilantin and aspirin
Diagnostic Lab Data: None
CDC 'Split Type': PR-55-21

Write-up: Resident did not express having any symptoms, the only thing that the POC observed abscesses in the arm, groin, thigh and knees after the first vaccination. After the second dose, he was hypoactive. On 2/27 at about 3:30 am he asked him to turn on his side, between 4 am and 5 am POC went to the room I notice it strange, because his head was wrapped in the sheet. When the POC removed the sheet, she observed that her mouth and nose were full of secretions. So he turned it and he himself did not react. He called the emergency who certifies that he had no vital signs. (emergency arrives within 5:45 am to 6:00 am)


Changed on 5/7/2021

VAERS ID: 1105115 Before After
VAERS Form:2
Age:18.0
Sex:Male
Location:Puerto Rico
Vaccinated:2021-02-14
Onset:2021-02-18
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Decreased activity, Groin abscess, Abscess limb, Increased upper airway secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-28
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: Keppra 1000 mg, Lamictal , Vimpat, Quetiapina, Lorazepam, Zyprexa, Motrin, Vitamina K, Acido Folico, Sultato Ferroso, Multivitam?nico Multivitamínico 365
Current Illness: None
Preexisting Conditions: Portal hypertension (secondary to portal vein thrombosis), Leukopenia, Thrombocytopenia, Epilepsy, Splenomegaly, Esophageal Varices, Asthma, Pancytopenia and Severe mental retardation.
Allergies: Dilantin and aspirin aspirin
Diagnostic Lab Data: None
CDC 'Split Type': PR-55-21

Write-up: Resident did not express having any symptoms, the only thing that the POC observed abscesses in the arm, groin, thigh and knees after the first vaccination. After the second dose, he was hypoactive. On 2/27 at about 3:30 am he asked him to turn on his side, between 4 am and 5 am POC went to the room I notice it strange, because his head was wrapped in the sheet. When the POC removed the sheet, she observed that her mouth and nose were full of secretions. So he turned it and he himself did not react. He called the emergency who certifies that he had no vital signs. (emergency arrives within 5:45 am to 6:00 am)


Changed on 5/21/2021

VAERS ID: 1105115 Before After
VAERS Form:2
Age:18.0
Sex:Male
Location:Puerto Rico
Vaccinated:2021-02-14
Onset:2021-02-18
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Decreased activity, Groin abscess, Abscess limb, Increased upper airway secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-28
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: Keppra 1000 mg, Lamictal , Vimpat, Quetiapina, Lorazepam, Zyprexa, Motrin, Vitamina K, Acido Folico, Sultato Ferroso, Multivitamínico Multivitam?nico 365
Current Illness: None
Preexisting Conditions: Portal hypertension (secondary to portal vein thrombosis), Leukopenia, Thrombocytopenia, Epilepsy, Splenomegaly, Esophageal Varices, Asthma, Pancytopenia and Severe mental retardation.
Allergies: Dilantin and aspirin aspirin
Diagnostic Lab Data: None
CDC 'Split Type': PR-55-21

Write-up: Resident did not express having any symptoms, the only thing that the POC observed abscesses in the arm, groin, thigh and knees after the first vaccination. After the second dose, he was hypoactive. On 2/27 at about 3:30 am he asked him to turn on his side, between 4 am and 5 am POC went to the room I notice it strange, because his head was wrapped in the sheet. When the POC removed the sheet, she observed that her mouth and nose were full of secretions. So he turned it and he himself did not react. He called the emergency who certifies that he had no vital signs. (emergency arrives within 5:45 am to 6:00 am)


Changed on 1/14/2022

VAERS ID: 1105115 Before After
VAERS Form:2
Age:18.0
Sex:Male
Location:Puerto Rico
Vaccinated:2021-02-14
Onset:2021-02-18
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 UN / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Decreased activity, Groin abscess, Abscess limb, Increased upper airway secretion

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-28
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: Keppra 1000 mg, Lamictal , Vimpat, Quetiapina, Lorazepam, Zyprexa, Motrin, Vitamina K, Acido Folico, Sultato Ferroso, Multivitam?nico Multivitam�nico 365
Current Illness: None
Preexisting Conditions: Portal hypertension (secondary to portal vein thrombosis), Leukopenia, Thrombocytopenia, Epilepsy, Splenomegaly, Esophageal Varices, Asthma, Pancytopenia and Severe mental retardation.
Allergies: Dilantin and aspirin
Diagnostic Lab Data: None
CDC 'Split Type': PR-55-21

Write-up: Resident did not express having any symptoms, the only thing that the POC observed abscesses in the arm, groin, thigh and knees after the first vaccination. After the second dose, he was hypoactive. On 2/27 at about 3:30 am he asked him to turn on his side, between 4 am and 5 am POC went to the room I notice it strange, because his head was wrapped in the sheet. When the POC removed the sheet, she observed that her mouth and nose were full of secretions. So he turned it and he himself did not react. He called the emergency who certifies that he had no vital signs. (emergency arrives within 5:45 am to 6:00 am)

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