National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 10/15/2021 release of VAERS data:

This is VAERS ID 1021171



Case Details

VAERS ID: 1021171 (history)  
Form: Version 2.0  
Age: 84.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-02-03
Onset:2021-02-04
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-04
   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: Albuterol, ASA, Zyrtec, D3, CPAP, Zetia, FeSO4, Flonase, Lantus, Atrovent solution, Losartan, Melatonin, Reglan, Metoprolol Succinate, Pantoprazole, Paroxetine, Polyethylene Glycol, Sucralfate, Tamsulosin, Stiolto Respimat
Current Illness: Hypertension, chest pain x 1 month, nausea (1/18/21 primary care visit); memory loss, small left cerebellar infarct (neurology 2/1/21)
Preexisting Conditions: HTN, CAD, cerebellar dysfunction, claudication, old myocardial infarction, COPD/dyspnea/sleep apnea, hx thoracic aortic aneurysm, CHF, DM II (insulin dependent), CKD stage 3, anemia, irregular heartbeat, PVC, hx of smoking, atelectasis, BPH, vascular dementia, angina of effort, GERD/abnormal barium swallow/DM gastroparesis, dyslipidemia, depression
Allergies: Statin intolerance (muscle tightening)
Diagnostic Lab Data: NA
CDC Split Type:

Write-up: Patient received first dose of Moderna COVID-19 vaccine on 2/3/21. Primary Care physician received call from coroner''s office 2/8/21 asking for information contributing to cause of death. Per Primary Care Physician notes, wife states she and patient took turns shoveling snow on 2/4/21. On one trip back into the house she found him unresponsive on the floor and called 911. Paramedics were unable to revive patient and he passed away (2/4/21).


New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1021171

Government Disclaimer on use of this data


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166