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VAERS ID: 2265775

AGE: 73| SEX: M|State: FL

Description

Systemic: Metastatic Stage 4 Melanoma, Broken hip, Significant blood clot in right leg, UTI, Multiple bilateral pulmonary nodules-Severe

Symptoms

Hip fracture, Urinary tract infection, Malignant melanoma stage IV, Metastatic malignant melanoma, Pulmonary mass, Thrombosis

Vaccines

VAX DATE: 20 December 2021 | ONSET DATE: 05 March 2022 | DAYS TO ONSET: 75
Vaccine TypeManufacturerVaccine NameDoseRouteSiteLot
  • COVID19
  • MODERNA
  • COVID19 (COVID19 (MODERNA))
  • 3
  • IM
  • RA
  • 067F21A

RECVDATE:
05 May 2022
CAGE_YR:
73
CAGE_MO:
RPT_DATE:
DIED:
DATEDIED:
L_THREAT:
ER_VISIT:
HOSPITAL:
Y
HOSPDAYS:
X_STAY:
DISABLE:
RECOVD:
N
LAB_DATA:
V_ADMINBY:
PHM
OTHER_MEDS:
CUR_ILL:
HISTORY:
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:
2
TODAYS_DATE:
05 May 2022
BIRTH_DEFECT:
OFC_VISIT:
ER_ED_VISIT:
ALLERGIES:
V_FUNDBY:
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