| VAERS ID: |
1112164 (history) |
| Form: |
Version 2.0 |
| Age: |
46.0 |
| Sex: |
Male |
| Location: |
Minnesota |
| Vaccinated: | 2021-03-04 |
| Onset: | 2021-03-06 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-03-18 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 2 |
UN / IM |
Administered by: Other Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-07
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Individual was a number of medications. His Psyciatrist wants Clozapine Emphasized CARBAMAZEPINE 200 MG TABLET Carbamazaepine 100mg ER Tab 12h Clozapine FLUTICASONE PROP 50 MCG SPRAY FOLIC ACID 1 MG TABLET Gabapentin 300mg caps Gabapentin
Current Illness: Had COVID November
Preexisting Conditions: 299.00 - Autistic disorder, current or active state 307.50 - Eating disorder, unspecified PICA 318.0 - Moderate mental retardation 493.9 - Asthma, unspecified 780.39 - Other convulsions
Allergies: Amoxicillan Lactose
Diagnostic Lab Data: Unknown
CDC Split Type: Unknown
Write-up: lndividual Suddenly passed away on 3/7/21.....His Psychiartrist stated that there could be an adverse effect with COVID, the COVID Vaccination and medications, with an emphasis on Clozapine |
