| VAERS ID: |
944732 (history) |
| Form: |
Version 2.0 |
| Age: |
92.0 |
| Sex: |
Male |
| Location: |
Wisconsin |
| Vaccinated: | 2021-01-13 |
| Onset: | 2021-01-14 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-14 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
037K2OA / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Pulse absent,
Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), 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: 2021-01-14
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: Cholecalciferol, furosemide, metoprolol tartrate, tamsulosin, amlodipine, finasteride
Current Illness: Covid-19 infection from 12/31-01/10/2021
Preexisting Conditions: CHF, atrial fibrilation, Dysphagia, macular degeneration, Vitamin D deficiency, impaired fasting glucose, benign prostatic hyperplasia, osteoporosis, retention of urine, anemia
Allergies: hydrocodone
Diagnostic Lab Data: None.
CDC Split Type:
Write-up: Resident found unresponsive and without pulse at 05:45am. |
