| VAERS ID: |
941561 (history) |
| Form: |
Version 2.0 |
| Age: |
91.0 |
| Sex: |
Male |
| Location: |
Minnesota |
| Vaccinated: | 2021-01-07 |
| Onset: | 2021-01-08 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-13 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011L20A / UNK |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Cerebrovascular accident,
Death,
Decreased appetite,
Grip strength decreased,
Hemiplegia,
Hypotonia,
Speech disorder,
Weight decreased
SMQs:, Peripheral neuropathy (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (narrow), Hypotonic-hyporesponsive episode (broad), Generalised convulsive seizures following immunisation (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-11
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Escitalopram Oxalate, Metformin ER, Systane balance, Colace, Refresh tears, Milk of Magnesia, Diltiazem
Current Illness: Resident was on hospice for Alzheimer''s disease.
Preexisting Conditions: Alzheimer''s Disease, Type II diabetes, Major depression disorder, Elevated B/P readings with Hypertension, history of stroke (7/22/2019 - Acute Lacunar Stroke)
Allergies: No known Allergies
Diagnostic Lab Data: Resident was declining for some time. He normally had a high heart rate. Appetite was poor with a significant weight loss noted.
CDC Split Type:
Write-up: Staff walked into resident''s room around 10:00am and noted resident''s left side of his face was flaccid. Nurse was called and upon assessment resident noted to have an unequal hand grasp with left worse. He was able to talk but was mumbled and hard to understand. Physician, hospice, and family were notified. Resident had a stroke at 10:06 am on 1/8/2020. He lost all ability to use his left side. Resident passed away on 1/11/2020. |
