| VAERS ID: |
947662 (history) |
| Form: |
Version 2.0 |
| Age: |
84.0 |
| Sex: |
Male |
| Location: |
Minnesota |
| Vaccinated: | 2020-12-30 |
| Onset: | 2021-01-01 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-15 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
037K20A / 1 |
RA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Death,
General physical health deterioration,
Hypophagia,
Hyporesponsive to stimuli,
Somnolence
SMQs:, Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (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: 2021-01-06
Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Terazosin 5mg po HS, Metoprolol 12.5 mg BID, Depakote 375mg BID, Hydrochlorothiazide 12.5mg Q am
Current Illness: no acute illnesses
Preexisting Conditions: Alzheimers, Dementia without behaviors, Chronic Venous hypertension, Aphasia, Benign Prostatic Hypertrophy, Aphasia, Osteoarthritis
Allergies: Lisinopril
Diagnostic Lab Data: None completed- Resident was determined to be at end of life
CDC Split Type:
Write-up: Accelerated decline in condition with decreased input, decreased responsiveness, somnolence, and death |
