National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 9/3/2021 release of VAERS data:

This is VAERS ID 909095



Case Details

VAERS ID: 909095 (history)  
Form: Version 2.0  
Age: 66.0  
Sex: Male  
Location: Colorado  
Vaccinated:2020-12-23
Onset:2020-12-25
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2020-12-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Foaming at mouth, Pain in extremity, Pallor, Pulse absent, Respiratory arrest, Somnolence, Unresponsive to stimuli
SMQs:, Anaphylactic reaction (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Dementia (broad), Convulsions (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad), Hypersensitivity (broad), Respiratory failure (narrow), Tendinopathies and ligament disorders (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-12-25
   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: Tamsulosin 0.4mg, Lactobacillus tablet, Nephro-vite tablet 0.8mg, Allopurinol 100mg, ferrous gluconate 324mg, melatonin 6mg, lisinopril 2.5mg, colace 100mg, metamucil powder, aspirin 81mg, amidoarone 200mg, hydrooxyzine 25mg, cholestyramine
Current Illness: End stage renal disease with dependence on renal dialysis, COPD, cirrhosis of the liver, hypokalemia, gout, heart failure, hyperlipidemia, atrial fibrillation.
Preexisting Conditions: Refused dialysis frequently resulting in episodes of hypokalemia and hospitalization, resident dependent on supplemental oxygen. The resident refused to go to dialysis on 12/23/2020 and said he was feeling fine.
Allergies: alprazolam, Lorazepam
Diagnostic Lab Data: None
CDC Split Type:

Write-up: on 12/24/2020 the resident was sleepy and stayed in bed most of the shift. He stated he was doing okay but requested pain medication for his legs at 250PM. At 255AM on 12/25/2020 the resident was observed in bed lying still, pale, eyes half open and foam coming from mouth and unresponsive. He was not breathing and with no pulse


New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=909095


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