National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 10/15/2021 release of VAERS data:

This is VAERS ID 1105749



Case Details

VAERS ID: 1105749 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Male  
Location: California  
Vaccinated:2021-01-29
Onset:2021-02-28
   Days after vaccination:30
Submitted: 0000-00-00
Entered: 2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-28
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Ceftazidime 1500mg IP every day Vancomycin 1500mg IP twice weekly Diflucan 100mg PO every day Epogen SQ 16,000 units weekly Icodextrin 2500mL IP daily Nepro PO daily Potassium Chloride 20mEq PO daily ASA 81mg PO every day Atorvastatin Calc
Current Illness: Peritonitis (MRSA)
Preexisting Conditions: CHF Diabetes Type 2 Insulin dependent ESRD
Allergies: Heparin
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Patient died on 2/28/2021


New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1105749

Government Disclaimer on use of this data


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166