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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1271626



Case Details

VAERS ID: 1271626 (history)  
Form: Version 2.0  
Age: 78.0  
Sex: Male  
Location: Georgia  
Vaccinated:2021-04-21
Onset:2021-04-22
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-04-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0071321A / 2 - / -

Administered by: Private       Purchased by: ?
Symptoms: Body temperature increased, Chest pain, Fall, Gait inability, Headache, Laboratory test, Malaise, Nausea, Oropharyngeal pain, Rhabdomyolysis, Vomiting
SMQs:, Rhabdomyolysis/myopathy (narrow), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dystonia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-29
   Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: FLOMAX 0.4MG DAILY IBUPROFEN AS NEEDED
Current Illness: NONE REPORTED
Preexisting Conditions: HYPERLIPIDEMIA
Allergies: NO KNOWN DRUG ALLERGIES REPORTED
Diagnostic Lab Data: LAB TESTING AT MLMC DURING ER AND OBS STAY 04/24-04/26/2021 AND 04/27/2021-04/28/2021
CDC Split Type:

Write-up: SPOUSE REPORTS THE FOLLOWING FOR PATIENT 4/21/2021 @ 9PM GENERAL MALAISE 4/22/2021 APPROX 4AM SEVERE HEADACHE TOOK IBUPROFEN 4/23/2021 AFTER LUNCH, PATIENT WAS UNABLE TO WALK AS PREVIOUS AND HAD 4 FALLS, ALSO COMPLAINED OF A SORE THROAT. 4/24/2021 DID NOT FEEL WELL, TEMP UP TO 100.4, NAUSEA AND VOMITTING X 1 AND CHEST PAIN, CALLED EMS AND WAS TRANSPORTED TO MEDICAL CENTER ER. 4/26/2021 PATIENT WAS DISCHAGED HOME AFTER TREATMENT FOR RHABDOMYOLYSIS AND RETURNED TO THE HOSTPITAL AGAIN ON 04/27/2021 WITH RHABDOMYOLYSIS AS PRIMARY DIAGNSOSIS. RESIDENT DISCHARGED TO SNF ON 04/28/2021.


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1271626

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