National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 7/16/2021 release of VAERS data:

This is VAERS ID 958228



Case Details

VAERS ID: 958228 (history)  
Form: Version 2.0  
Age: 83.0  
Sex: Male  
Location: Illinois  
Vaccinated:2021-01-12
Onset:2021-01-18
   Days after vaccination:6
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 0329K20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase normal, Blood albumin decreased, Blood alkaline phosphatase increased, Blood bilirubin normal, Blood calcium normal, Blood chloride increased, Blood creatinine increased, Blood glucose increased, Blood potassium increased, Blood sodium increased, Blood urea increased, Carbon dioxide decreased, Death, Diet refusal, Hypernatraemia, Metabolic function test, Protein total normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Liver related investigations, signs and symptoms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Retroperitoneal fibrosis (broad), Biliary system related investigations, signs and symptoms (broad), Chronic kidney disease (broad), Tumour lysis syndrome (narrow), Tubulointerstitial diseases (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   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: 1) AMLODIPINE BESYLATE TAB 5MG PO QPM ACTIVE 2) ASPIRIN (OTC) TAB,CHEWABLE 81MG PO QDAILY ACTIVE 3) CARVEDILOL TAB 12.5MG PO BID ACTIVE 4) CHOLECALCIFEROL (VIT D3) 25MCG=100
Current Illness: none other than chronic conditions as listed under item 12.
Preexisting Conditions: acute on chronic kidney failure, Alzheimer''s dementia, diabetes mellitus type II, hypothyroidism, bipolar disorder, hypertension, hyperlipidemia
Allergies: Niacin - rash
Diagnostic Lab Data: Collection time: Jan 17, 2021@06:00 Test Name Result Units Range --------- ------ ----- ----- GLUCOSE 166H mg/dL 70 - 99 UREA NITROGEN 138H mg/dL 7 - 18 CREATININE 6.93H mg/dL .7 - 1.3 SODIUM 165H* mmol/L 136 - 145 POTASSIUM 5.2H mmol/L 3.5 - 5.1 CHLORIDE 130H mmol/L 98 - 107 CO2 21 mmol/L 21 - 32 CALCIUM, TOTAL 9.2 mg/dL 8.5 - 10.1 PROTEIN, TOTL 7.8 g/dL 6.4 - 8.2 ALBUMIN 3.2L g/dL 3.4 - 5.0 AST 16 U/L 15 - 37 ALT 22 U/L 16 - 63 BILI,TOTAL 0.3 mg/dL 0.2 - 1.0 ALKAL PHOS 168H U/L 46 - 116 EGFR canc ANION GAP 20.0 mmol/L 10 - 20
CDC Split Type:

Write-up: Patient has end stage renal disease and rapidly worsening dementia, family could no longer care for him at home, and he was admitted for 14-day quarantine prior to admission to inpatient hospice. Received vaccine on 1/12 without apparent adverse reactions. Patient started refusing oral intake on 1/16, and CMP on 1/17 showed hypernatremia 165 (new issue). His BUN 138 CREAT 6.93 K 5.2 were his baseline. He was found to be deceased on 1/18 at 11:18 pm.


New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=958228


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