| VAERS ID: |
947129 (history) |
| Form: |
Version 2.0 |
| Age: |
101.0 |
| Sex: |
Female |
| Location: |
Georgia |
| Vaccinated: | 2020-12-23 |
| Onset: | 2020-12-25 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
026L20A / 1 |
AR / IM |
Administered by: Private Purchased by: ?
Symptoms: Cerebrovascular accident,
Death
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Haemorrhagic central nervous system vascular conditions (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-01
Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin, Digoxin, Diltiazem CR, Namenda CR, Toprol XL, Acetaminophen, Vitamin D, Zyrtec
Current Illness: Anemia, cardiac murmur, atrial fibrillation, osteoporosis, dysphagia, hyperlipidemia, muscle weakness, aortic valve stenosis
Preexisting Conditions: Anemia, cardiac murmur, atrial fibrillation, osteoporosis, dysphagia, hyperlipidemia, muscle weakness, aortic valve stenosis
Allergies: None known
Diagnostic Lab Data:
CDC Split Type:
Write-up: Resident received Moderna vaccine on 12/23/2020 around 5 pm. At approximately 3:35 am on 12/25/2020, resident had a CVA and died on 1/1/2021 at 3:00 am. |
