VAERS ID: |
910363 (history) |
Form: |
Version 2.0 |
Age: |
84.0 |
Sex: |
Male |
Location: |
California |
Vaccinated: | 2020-12-23 |
Onset: | 2020-12-26 |
Days after vaccination: | 3 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-28 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
LOT 039K20A / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Death,
Hypophagia,
Hypotension,
Somnolence SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-28
Days after onset: 2
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: risperidone daily doxazosin Current Illness: dementia declining oral intake Preexisting Conditions: history of aspiration pneumonia BPH Allergies: none Diagnostic Lab Data: none CDC Split Type:
Write-up: Patient had mild hypotension, decreased oral intake, somnolence starting 3 days after vaccination and death 5 days after administration. He did have advanced dementia and was hospice eligible based on history of aspiration pneumonia. |