| VAERS ID: |
1030712 (history) |
| Form: |
Version 2.0 |
| Age: |
74.0 |
| Sex: |
Male |
| Location: |
Michigan |
| Vaccinated: | 2021-02-09 |
| Onset: | 2021-02-10 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-02-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
004M20A / 2 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Chills,
Death,
Decreased appetite,
Depressed level of consciousness,
Fatigue,
Food refusal,
Loss of consciousness,
Pyrexia,
Respiratory rate increased
SMQs:, Torsade de pointes/QT prolongation (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-12
Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: NA
Current Illness: In the hospital one week prior to vaccination for decreased LOC, and lack of appetite
Preexisting Conditions: non-Hodgkin lymphoma, epilepsy, advanced dementia, SDH, depression, COVID-19, malnutrition
Allergies: NKDA
Diagnostic Lab Data:
CDC Split Type:
Write-up: 2/10: Fever, fatigue, tylenol 2/11 @ 1300: pt made DNR, hospice consulted 2/11 @ 1800 decreased LOC, increased RR, fever, chills - 1/5L NS bolus IV, rectal tylenol. Refusing to eat/drink, PO morphine 2/12 @ 16:30, deceased at facility **resident was not doing well prior to vaccination |
