VAERS ID: |
936805 (history) |
Form: |
Version 2.0 |
Age: |
25.0 |
Sex: |
Male |
Location: |
Kentucky |
Vaccinated: | 2020-12-22 |
Onset: | 2021-01-11 |
Days after vaccination: | 20 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-12 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
039K20A / 1 |
RA / IM |
Administered by: Private 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: 2021-01-11
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: See Continuation Field Current Illness: Whiplash injury to neck. Sprain of ligaments of cervical spine Preexisting Conditions: Septal defect (heart), chronic sinusitis Allergies: Ceftriaxone Diagnostic Lab Data: None associated. CDC Split Type:
Write-up: Patient received the vaccine on 12/22/20 without complication. It was reported today that the patient was found unresponsive and subsequently expired at home on 1/11/21. |