| VAERS ID: |
921572 (history) |
| Form: |
Version 2.0 |
| Age: |
87.0 |
| Sex: |
Male |
| Location: |
Wisconsin |
| Vaccinated: | 2020-12-29 |
| Onset: | 2020-12-30 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-05 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Chills,
Death,
Fall,
Hip fracture,
Oxygen saturation decreased,
Pain,
Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Osteoporosis/osteopenia (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Infective pneumonia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-02
Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Fluticasone, Lasix, Omeprazole, Sucarafate, Ropinrole HCl
Current Illness: Heart Failure
Preexisting Conditions: Chronic Kidney Disease, Atherosclerotic Heart Disease
Allergies: Lisinopril, Losartan
Diagnostic Lab Data:
CDC Split Type:
Write-up: Resident had body aches, a low O2 sat and had chills starting on 12/30/20. He had stated that they had slightly improved. On 1/1/21 he sustained a fall with a diagnosis of a displaced hip fracture. On 1/2/21 during the NOC shift his O2 sat dropped again. He later went unresponsive and passed away. |
