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 1116386



Case Details

VAERS ID: 1116386 (history)  
Form: Version 2.0  
Age: 68.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-03-12
Onset:2021-03-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-03-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 007M20A / 2 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Death, Fatigue, Nausea, Unresponsive to stimuli, Vomiting
SMQs:, Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-18
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: synthroid, rosuvastatin, levemir, xarelto, metformin, omeprazole, proair
Current Illness:
Preexisting Conditions: diabetes, CAD, a-fib
Allergies: cat dander, diazepam
Diagnostic Lab Data: unknown
CDC Split Type:

Write-up: Patient developed nausea and vomiting 3/14/21. was seen at clinic by this provider 3/16/21 and reported at that time continued fatigue but overall symptom improvement. Vital signs were stable. pt was advised to orally hydrate and routinely monitor blood sugars and f/u as needed. On 3/18/21 patient was found down in his motel room by shelter staff unresponsive. 911 was called. pt transported to hospital by EMS receiving BLS. Clinic staff was advised by family that patient was pronounced dead that date.


New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1116386

Government Disclaimer on use of this data


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