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This is VAERS ID 910363

History of Changes from the VAERS Wayback Machine

First Appeared on 12/30/2020

VAERS ID: 910363
VAERS Form:2
Age:84.0
Sex:Male
Location:California
Vaccinated:2020-12-23
Onset:2020-12-26
Submitted:0000-00-00
Entered:2020-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA LOT 039K20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Hypotension, Somnolence, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-28
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: risperidone daily doxazosin
Current Illness: dementia declining oral intake
Preexisting Conditions: history of aspiration pneumonia BPH
Allergies: none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient had mild hypotension, decreased oral intake, somnolence starting 3 days after vaccination and death 5 days after administration. He did have advanced dementia and was hospice eligible based on history of aspiration pneumonia.


Changed on 5/7/2021

VAERS ID: 910363 Before After
VAERS Form:2
Age:84.0
Sex:Male
Location:California
Vaccinated:2020-12-23
Onset:2020-12-26
Submitted:0000-00-00
Entered:2020-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA LOT 039K20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Hypotension, Somnolence, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-28
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: risperidone daily doxazosin
Current Illness: dementia declining oral intake
Preexisting Conditions: history of aspiration pneumonia BPH
Allergies: none none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient had mild hypotension, decreased oral intake, somnolence starting 3 days after vaccination and death 5 days after administration. He did have advanced dementia and was hospice eligible based on history of aspiration pneumonia.


Changed on 5/14/2021

VAERS ID: 910363 Before After
VAERS Form:2
Age:84.0
Sex:Male
Location:California
Vaccinated:2020-12-23
Onset:2020-12-26
Submitted:0000-00-00
Entered:2020-12-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA LOT 039K20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Hypotension, Somnolence, Hypophagia

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-12-28
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: risperidone daily doxazosin
Current Illness: dementia declining oral intake
Preexisting Conditions: history of aspiration pneumonia BPH
Allergies: none none
Diagnostic Lab Data: none
CDC 'Split Type':

Write-up: Patient had mild hypotension, decreased oral intake, somnolence starting 3 days after vaccination and death 5 days after administration. He did have advanced dementia and was hospice eligible based on history of aspiration pneumonia.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=910363&WAYBACKHISTORY=ON


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