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

This is VAERS ID 1222565



Case Details

VAERS ID: 1222565 (history)  
Form: Version 2.0  
Age: 93.0  
Sex: Male  
Location: Puerto Rico  
Vaccinated:2021-03-03
Onset:2021-03-05
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-04-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 2 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cardio-respiratory arrest, Dysphagia
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Respiratory failure (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-05
   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: Lisinopril, Vitamin D3,Vitamina c Donepezil, Trazadone, Metoprolol
Current Illness: None reported
Preexisting Conditions: Advanced Stage Alzheimer''s, Hypertensive, Hospice
Allergies: None reported
Diagnostic Lab Data: None reported
CDC Split Type:

Write-up: Resident was in Hospice and began to stops wallowing. Respiratory cardiac arrest


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1222565

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