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This is VAERS ID 1106667

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1106667
VAERS Form:2
Age:67.0
Sex:Male
Location:California
Vaccinated:2021-03-12
Onset:2021-03-13
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Asthenia, Death, Feeling abnormal, Resuscitation, Eye movement disorder

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-13
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: amlodipine 5 mg daily, carvedilol 12.5 mg twice daily, furosemide 80 mg twice daily, sevelamer 800 mg 2 with meals tid, terazosin 2 mg daily, pantoprazole 20 mg daily if needed for heartburn, cinacalcet 30 mg daily
Current Illness: DM 2 with ESRD, hyperlipidemia, vascular disease, autonomic neuropathy, retinopathy, CAD w hx of CABG and coronary artery stent, chondrocalcinosis, gout. also hx of covid disease 6/3/2020. anemia renal disease, hyperparathyroidism of renal failure. hx smoking. hx stroke and TIAs; hx of subdural hematoma .
Preexisting Conditions: see above.
Allergies: penicillin
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Information here obtained from daughter: on Thursday patient had an uneventful fistulagram with angioplasty. Patient got vaccine at end of usual Friday am dialysis treatment. He was observed for about 30" and no untoward event noted, vitals usual. At home on Saturday morning, seemed not quite himself by wife as reported by daughter, from whom i got his information. He gets up late as hemodialysis starts at 515 am. No reported problems on Friday. On Saturday morning, he seemed not himself but sat down and ate breakfast around 9 am. On getting up from table he got suddenly weak, his head rolled back and his eyes rolled up. 911 called and he was given resuscitation efforts of unknown duration which were unsuccessful. He was pronounced dead at 11 am and the mortuary was called. No premortem labs, et al.

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