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This is VAERS ID 1759634

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First Appeared on 10/8/2021

VAERS ID: 1759634
VAERS Form:2
Age:78.0
Sex:Male
Location:Michigan
Vaccinated:2021-09-22
Onset:2021-09-27
Submitted:0000-00-00
Entered:2021-10-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 939902 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Basophil count normal, Chest X-ray abnormal, Death, Dyspnoea, Eosinophil count normal, Fatigue, Haematocrit decreased, Haemoglobin decreased, Lung infiltration, Lymphocyte count decreased, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume normal, Monocyte count normal, Neutrophil count normal, Platelet count decreased, Red blood cell count decreased, Prealbumin decreased, Neutrophil percentage increased, Lymphocyte percentage decreased, Red cell distribution width increased, Mean platelet volume normal, Acquired diaphragmatic eventration, Eosinophil percentage, Basophil percentage, Monocyte percentage, Adult failure to thrive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-10-01
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: 4 oz. house supplement with meals. Administer SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 100 mcg/0.5 mL dose, 2-dose vaccine (Moderna) To receive dose #1 on 8/11/21 1 Administer SARS-COV-2 (COVID-19) vacc
Current Illness: Diagnoses: ANEMIA, UNSPECIFIED(D64.9), UNSPECIFIED PROTEIN-CALORIE MALNUTRITION(E46), ADULT FAILURE TO THRIVE(R62.7), PERSONAL HISTORY OF OTHER MALIGNANT NEOPLASM OF STOMACH(Z85.028), TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS(E11.9), ANXIETY DISORDER, UNSPECIFIED(F41.9), UNSPECIFIED FALL, SUBSEQUENT ENCOUNTER(W19.XXXD), DIAPHRAGMATIC HERNIA WITHOUT OBSTRUCTION OR GANGRENE(K44.9), DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED(R26.2), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE(M62.50), DYSPHAGIA, OROPHARYNGEAL PHASE(R13.12), LOW BACK PAIN(M54.5), IDIOPATHIC HYPOTENSION (I95.0), CONSTIPATION, UNSPECIFIED(K59.00), PRESSURE ULCER OF OTHER SITE, STAGE 1(L89.891), CHRONIC KIDNEY DISEASE, STAGE 3 UNSPECIFIED(N18.30)
Preexisting Conditions: Diagnoses: ANEMIA, UNSPECIFIED(D64.9), UNSPECIFIED PROTEIN-CALORIE MALNUTRITION(E46), ADULT FAILURE TO THRIVE(R62.7), PERSONAL HISTORY OF OTHER MALIGNANT NEOPLASM OF STOMACH(Z85.028), TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS(E11.9), ANXIETY DISORDER, UNSPECIFIED(F41.9), UNSPECIFIED FALL, SUBSEQUENT ENCOUNTER(W19.XXXD), DIAPHRAGMATIC HERNIA WITHOUT OBSTRUCTION OR GANGRENE(K44.9), DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED(R26.2), MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE(M62.50), DYSPHAGIA, OROPHARYNGEAL PHASE(R13.12), LOW BACK PAIN(M54.5), IDIOPATHIC HYPOTENSION (I95.0), CONSTIPATION, UNSPECIFIED(K59.00), PRESSURE ULCER OF OTHER SITE, STAGE 1(L89.891), CHRONIC KIDNEY DISEASE, STAGE 3 UNSPECIFIED(N18.30)
Allergies: No Known Allergies
Diagnostic Lab Data: |AGE: 78 GENDER: M | DATE&TIME: | 07/16/21 11:49 | |RCVD: 07/16/21 | |RPTD: 07/16/21 | RM 133 R E S U L T S RBC 3.71(L) 4.10-6.20 10^6/uL HEMOGLOBIN 10.0(L) 13.5-17.5 g/dL HEMATOCRIT 29.8(L) 41.0-53.0 % MCV 80 80.0-97.0 fL MCH 27.0 26.0-32.0 pg/cell MCHC 33.6 32.0-37.0 g/dL RDW 17.9(H) 11.5-14.5 % MPV 10.3 7.5-11.2 fl PLATELET COUNT 97(L) 130-400 10^3/uL NEUTROPHIL% 81.1(H) 40.0-74.0 % LYMPHOCYTE% 11.3(L) 19.0-48.0 % MONOCYTES% 6.2 2.0-11.0 % EOSONOPHIL% 0.7 0.0-7.0 % BASOPHIL% 0.7 0.0-1.5 % NEUTROPHIL# 5.7 1.7-7.7 10^3/uL LYMPHOCYTE# 0.8(L) 1.0-4.8 10^3/uL MONOCYTE# 0.4 0.0-1.0 10^3/uL EOSINOPHIL# 0.1 0.04-0.45 10^3/uL BASOPHIL# 0.1 0.00-0.20 10^3/uL MI PRE-ALBUMIN 11(L) 17.0-34.0 mg/dL INTERPRETATION: Reason for Study: R06.02 SHORTNESS OF BREATH XRAY CHEST 1 VIEW See Note FINDINGS: The heart is normal in size and configuration. The mediastinum is normal without adenopathy. There is a minimal right lower lobe infiltrate. There is no venous congestion. The osseous structures are unremarkable. CONCLUSION: Minimal right lower lobe infiltrate . The right hemidiaphragm is elevated
CDC 'Split Type':

Write-up: Guest passed/expired within 10 days of dose #2 of COVID-19 vaccine series. Began transitioning on 9/27/21-- 5 days s/p Dose #2. Guest was a hospice resident prior to COVID-19 vaccine and overall was having general decline prior to vaccination. Signed on to hospice on 8/6/21. Had active diagnosis of adult failure to thrive and hx of gastric CA--declined PEG tube. Only acute side effect 2 days s/p dose 2 noted was fatigue. No side side effects were reported with dose #1.

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