VAERS ID: |
918065 (history) |
Form: |
Version 2.0 |
Age: |
64.0 |
Sex: |
Male |
Location: |
California |
Vaccinated: | 2020-12-30 |
Onset: | 2021-01-01 |
Days after vaccination: | 2 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-04 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
025J20-2A / 1 |
- / IM |
Administered by: Other Purchased by: ? Symptoms: Death,
Unresponsive to stimuli SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), 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: 2021-01-01
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: - Invega Trenza 546mg Q3months - Lithium 300mg BID - Oxybutynin 5mg QID - lipitor 20mg QHS - cogentin 2mg BID - Norvasc 5mg QD - Dyazide Capsule 37.5-25 MG (Triamterene-HCTZ) QD Current Illness: - covid-19 Preexisting Conditions: - SCHIZOPHRENIA, UNSPECIFIED - ANEMIA, UNSPECIFIED - OVERWEIGHT - OVERACTIVE BLADDER - ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS - HYPOTHYROIDISM DUE TO MEDICAMENTS AND OTHER EXOGENOUS SUBSTANCES - NICOTINE DEPENDENCE, UNSPECIFIED, UNCOMPLICATED - CHRONIC VIRAL HEPATITIS C - UNSPECIFIED AGE-RELATED CATARACT - ESSENTIAL (PRIMARY) HYPERTENSION - CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED - UNSPECIFIED CONVULSIONS - INHALANT ABUSE, UNCOMPLICATED - OTHER SEIZURES Allergies: - Clozaril - Tegretol Diagnostic Lab Data: N/A CDC Split Type:
Write-up: 1/1/2020: Residents was found unresponsive. Pronounced deceased at 6:02pm |