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))

        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: