VAERS ID: |
956966 (history) |
Form: |
Version 2.0 |
Age: |
86.0 |
Sex: |
Male |
Location: |
Unknown |
Vaccinated: | 2020-12-25 |
Onset: | 2020-12-25 |
Days after vaccination: | 0 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-09 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
011J20A / 1 |
LA / IM |
Administered by: Other Purchased by: ? Symptoms: Body temperature increased,
Complication associated with device,
Cough,
Dyspnoea,
Hypoxia,
Secretion discharge SMQs:, Anaphylactic reaction (broad), Asthma/bronchospasm (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-25
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations: Other Medications: Current Illness: Preexisting Conditions: Allergies: Diagnostic Lab Data: CDC Split Type:
Write-up: hypoxia, secretions,cough, dyspnea Narrative: ALS patient on hospice with ongoing history of aspiration pna, receiving tube feeds. Developed incr in secretions, hypoxeia, temp and with recently noted clogged feeding tube. |