| VAERS ID: |
922977 (history) |
| Form: |
Version 1.0 |
| Age: |
71.0 |
| Sex: |
Male |
| Location: |
New York |
| Vaccinated: | 2020-12-21 |
| Onset: | 2020-12-27 |
| Days after vaccination: | 6 |
| Submitted: |
2020-12-28 |
| Days after onset: | 1 |
| Entered: |
2021-01-05 |
| Days after submission: | 8 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011J20A / 2 |
LA / - |
Administered by: Other Purchased by: Other
Symptoms: Pyrexia,
Respiratory depression,
SARS-CoV-2 test positive
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (narrow), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-28
Days after onset: 1
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions:
Allergies:
Diagnostic Lab Data:
CDC Split Type:
Write-up: Fever, RespDepression & COVID positive REMDESIVIR (EUA) 200 mg x1 then 100 mg daily |
