| VAERS ID: |
918487 (history) |
| Form: |
Version 2.0 |
| Age: |
94.0 |
| Sex: |
Male |
| Location: |
Michigan |
| Vaccinated: | 2020-01-02 |
| Onset: | 2021-01-04 |
| Days after vaccination: | 368 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-04 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011L2OA / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Cardiac arrest,
Death
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-04
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: Loratadine, Plavix, flomax, Lisinopril, atrovastatin, amlodipine, Pentoxifylline, ASA, Donepezil, trazodone, Metoprolol tartrate.
Current Illness: NSTEMI, Dementia, TIA, COVID-19, HTN, CVA, PVD
Preexisting Conditions: HTN, PVD, Dementia
Allergies: Beta Adrenergic Blockers
Diagnostic Lab Data: None
CDC Split Type:
Write-up: Two days post vaccine patient went into cardiac arrest and passed away. |
