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This is VAERS ID 1063812

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1063812
VAERS Form:2
Age:79.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-13
Onset:2021-01-13
Submitted:0000-00-00
Entered:2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Confusional state, Death, Dementia, Diet refusal, Laboratory test abnormal, Renal failure, Restlessness

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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:
Current Illness: severe CAD, DM type 2, and hx of RBKA and left 5 digits on foot amputation. Hx of osteomyelitis post surgical. Decreased appetite, more restless, increased confusion with dementia, On 1/25/21 Resident labs showed kidney failure, on 2/5/21 went on comfort care
Preexisting Conditions: severe CAD, DM type 2, and hx of RBKA and left 5 digits on foot amputation. Hx of osteomyelitis post surgical.
Allergies: Doxycycline
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident had severe CAD, DM type 2, and hx of RBKA and left 5 digits on foot amputation. Hx of osteomyelitis post surgical. After last surgery, resident did not have a good appetite, more restless, increased confusion with dementia. Significant other passed away on 12/30/20, resident began refusing meals, decreased eating. Vaccinated on 1/13/21. On 1/25/21 Resident labs showed kidney failure. Dr. spoke with family and transitioned to Comfort care, on 2/5/21 went hospice. Patient passed away on 2/13/2021.


Changed on 5/7/2021

VAERS ID: 1063812 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-13
Onset:2021-01-13
Submitted:0000-00-00
Entered:2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Confusional state, Death, Dementia, Diet refusal, Laboratory test abnormal, Renal failure, Restlessness

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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:
Current Illness: severe CAD, DM type 2, and hx of RBKA and left 5 digits on foot amputation. Hx of osteomyelitis post surgical. Decreased appetite, more restless, increased confusion with dementia, On 1/25/21 Resident labs showed kidney failure, on 2/5/21 went on comfort care
Preexisting Conditions: severe CAD, DM type 2, and hx of RBKA and left 5 digits on foot amputation. Hx of osteomyelitis post surgical.
Allergies: Doxycycline Doxycycline
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident had severe CAD, DM type 2, and hx of RBKA and left 5 digits on foot amputation. Hx of osteomyelitis post surgical. After last surgery, resident did not have a good appetite, more restless, increased confusion with dementia. Significant other passed away on 12/30/20, resident began refusing meals, decreased eating. Vaccinated on 1/13/21. On 1/25/21 Resident labs showed kidney failure. Dr. spoke with family and transitioned to Comfort care, on 2/5/21 went hospice. Patient passed away on 2/13/2021.


Changed on 5/21/2021

VAERS ID: 1063812 Before After
VAERS Form:2
Age:79.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-13
Onset:2021-01-13
Submitted:0000-00-00
Entered:2021-03-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Confusional state, Death, Dementia, Diet refusal, Laboratory test abnormal, Renal failure, Restlessness

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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:
Current Illness: severe CAD, DM type 2, and hx of RBKA and left 5 digits on foot amputation. Hx of osteomyelitis post surgical. Decreased appetite, more restless, increased confusion with dementia, On 1/25/21 Resident labs showed kidney failure, on 2/5/21 went on comfort care
Preexisting Conditions: severe CAD, DM type 2, and hx of RBKA and left 5 digits on foot amputation. Hx of osteomyelitis post surgical.
Allergies: Doxycycline Doxycycline
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident had severe CAD, DM type 2, and hx of RBKA and left 5 digits on foot amputation. Hx of osteomyelitis post surgical. After last surgery, resident did not have a good appetite, more restless, increased confusion with dementia. Significant other passed away on 12/30/20, resident began refusing meals, decreased eating. Vaccinated on 1/13/21. On 1/25/21 Resident labs showed kidney failure. Dr. spoke with family and transitioned to Comfort care, on 2/5/21 went hospice. Patient passed away on 2/13/2021.

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