VAERS ID: |
927260 (history) |
Form: |
Version 2.0 |
Age: |
87.0 |
Sex: |
Female |
Location: |
Wisconsin |
Vaccinated: | 2020-12-28 |
Onset: | 2021-01-06 |
Days after vaccination: | 9 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-07 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
037K20A / 1 |
AR / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Blood lactic acid increased,
Bradycardia,
Cardiac arrest,
Computerised tomogram head normal,
Death,
Heart sounds abnormal,
Pulse absent,
Respiration abnormal,
Resuscitation,
SARS-CoV-2 test negative,
Unresponsive to stimuli,
White blood cell count increased SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Lactic acidosis (narrow), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-06
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 1 days
Extended hospital stay? No Previous Vaccinations: Other Medications: Vit D3, Miralax, Spironolactone, Tramadol, Metoprolol Succinate, MOM, Ferrous Gluconate, Ondansetron, Nitroglycerin Sublingual PRN, PreserVision AREDS, Fluticasone Propionate Suspension, Lisinopril, Clopidogrel Bisulfate, Campor-Methol-Met Current Illness: Digestive Surgery for bowel obstruction Preexisting Conditions: HTN, AAA, Chronic Diastolic Heart Failure, Diabetes Type 2, Paroxysmal atrial fibrillation, bradycardia, Hx of STEMI, Hx of CVA, HX of uterine cancer, Allergies: Codeine, Meperidine, Morphine, Estrogens, Penicillins, Tetanus Toxoids Diagnostic Lab Data: Brain CT negative WBC and lactic acid increased. COVID 19 on 1/4/21 negative CDC Split Type:
Write-up: No adverse effects noted after vaccination. Patient with cardiac history was found unresponsive at 16:45 on 1/6/21. Abnormal breathing patterns, eyes partially closed SPO2 was 41%, pulseless with no cardiac sounds upon auscultation. CPR and pulse was regained and patient was breathing. Patient sent to Hospital ER were she remained in an unstable condition had multiple cardiac arrest and severe bradycardia and in the end the hospital was unable to bring her back. |