| VAERS ID: |
949474 (history) |
| Form: |
Version 2.0 |
| Age: |
79.0 |
| Sex: |
Male |
| Location: |
California |
| Vaccinated: | 2021-01-13 |
| Onset: | 2021-01-14 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
Respiratory arrest,
Vomiting
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypersensitivity (broad), Respiratory failure (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-14
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: Melatonin 3mg PO QHS Amlopidine Besylate 5mg PO QD Atorvastin Calcium 20mg PO QHS Carbidopa-Levodopa 25-100mg PO TID Multiple Vitamin 1 PO QD Senna 8.6mg PO BID Calcium-Vitamin D 600mg PO BID Metformin HCl 500mg PO BID Rivastigmine patch 9
Current Illness: None but he has History of COVID-19 previously when initially admitted to the facility.
Preexisting Conditions: Parkinson''s Disease, Diabetes Mellitus Type 2, Hyperlipidemia, Dementia, ASHD, Psychosis, Hypertension, Dysphagia, Acute Sinusitis
Allergies: NKA
Diagnostic Lab Data: None
CDC Split Type:
Write-up: Resident had lunch on 01/14/21 and after lunch around 2:00pm, he vomited and stopped breathing. We coded the resident and 911 paramedics came. They pronounced him dead at 2:18pm. |
