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This is VAERS ID 1126619

History of Changes from the VAERS Wayback Machine

First Appeared on 4/1/2021

VAERS ID: 1126619
VAERS Form:2
Age:92.0
Sex:Male
Location:California
Vaccinated:2021-03-19
Onset:2021-03-19
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-19
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: Folic Acid Tablet 1 MG Give 1 tablet by mouth one time a day for Anemia; Lasix Tablet 40 MG Give 1 tablet by mouth one time a day for PLEURAL EFFUSION for 3 days; Losartan Potassium Tablet 50 MG Give 1 tablet by mouth one time a day for HTN
Current Illness: METABOLIC ENCEPHALOPATHY; PERSONAL HISTORY OF TRANSIENT ISCHEMIC ATTACK (TIA); AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS; NUTRITIONAL ANEMIA; UNSPECIFIED; UNSPECIFIED ATRIAL FIBRILLATION; ESSENTIAL (PRIMARY) HYPERTENSION; VASCULAR DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE; OTHER ABNORMALITIES OF GAIT AND MOBILITY; MUSCLE WEAKNESS (GENERALIZED); UNSPECIFIED PROTEIN-CALORIE MALNUTRITION; PLEURAL EFFUSION, NOT ELSEWHERE CLASSIFIED; SECONDARY PULMONARY ARTERIAL HYPERTENSION, NONRHEUMATIC MITRAL (VALVE) INSUFFICIENCY; ATHEROSCLEROSIS OF AORTA; CARDIOMEGALY, CONTACT WITH AND (SUSPECTED) EXPOSURE TO COVID-19; DYSPHAGIA FOLLOWING OTHER CEREBROVASCULAR DISEASE, PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2; PRESSURE ULCER OF OTHER SITE, STAGE 2; PRESSURE-INDUCED DEEP TISSUE DAMAGE OF LEFT ANKLE.
Preexisting Conditions:
Allergies: No Known Allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: His vitals signs was stable after vaccine was administered, but the resident was expired in 85mins after given 1st dose of Covid Moderna vaccine.


Changed on 5/7/2021

VAERS ID: 1126619 Before After
VAERS Form:2
Age:92.0
Sex:Male
Location:California
Vaccinated:2021-03-19
Onset:2021-03-19
Submitted:0000-00-00
Entered:2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-19
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: Folic Acid Tablet 1 MG Give 1 tablet by mouth one time a day for Anemia; Lasix Tablet 40 MG Give 1 tablet by mouth one time a day for PLEURAL EFFUSION for 3 days; Losartan Potassium Tablet 50 MG Give 1 tablet by mouth one time a day for HTN
Current Illness: METABOLIC ENCEPHALOPATHY; PERSONAL HISTORY OF TRANSIENT ISCHEMIC ATTACK (TIA); AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS; NUTRITIONAL ANEMIA; UNSPECIFIED; UNSPECIFIED ATRIAL FIBRILLATION; ESSENTIAL (PRIMARY) HYPERTENSION; VASCULAR DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE; OTHER ABNORMALITIES OF GAIT AND MOBILITY; MUSCLE WEAKNESS (GENERALIZED); UNSPECIFIED PROTEIN-CALORIE MALNUTRITION; PLEURAL EFFUSION, NOT ELSEWHERE CLASSIFIED; SECONDARY PULMONARY ARTERIAL HYPERTENSION, NONRHEUMATIC MITRAL (VALVE) INSUFFICIENCY; ATHEROSCLEROSIS OF AORTA; CARDIOMEGALY, CONTACT WITH AND (SUSPECTED) EXPOSURE TO COVID-19; DYSPHAGIA FOLLOWING OTHER CEREBROVASCULAR DISEASE, PRESSURE ULCER OF RIGHT BUTTOCK, STAGE 2; PRESSURE ULCER OF OTHER SITE, STAGE 2; PRESSURE-INDUCED DEEP TISSUE DAMAGE OF LEFT ANKLE.
Preexisting Conditions:
Allergies: No Known Allergies Allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: His vitals signs was stable after vaccine was administered, but the resident was expired in 85mins after given 1st dose of Covid Moderna vaccine.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1126619&WAYBACKHISTORY=ON


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