| VAERS ID: |
1012047 (history) |
| Form: |
Version 2.0 |
| Age: |
57.0 |
| Sex: |
Female |
| Location: |
Missouri |
| Vaccinated: | 2021-02-01 |
| Onset: | 2021-02-06 |
| Days after vaccination: | 5 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-08 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025L20A / 2 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Acidosis,
Cardiac arrest,
Encephalopathy,
Endotracheal intubation,
Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Lactic acidosis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (narrow), Cardiomyopathy (broad), Chronic kidney disease (broad), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Immune-mediated/autoimmune disorders (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-07
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine Besylate; Antacid Suspension; Atorvastatin Calcium; Atropine Sulfate; Clozaril; Cyanocobalamin; metformin HCl; Metoprolol Tartrate; Tylenol
Current Illness: DMII
Preexisting Conditions: Tobacco use, Schizophrenia, DMII, Bipolar, HTN, COVID 19 hx,
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:
Write-up: Sudden death 2/7/21 @ 0309 Started acute encephalopathy & required intubation Soon after intubation went into cardiac arrest Likely severe acidosis. |
