| VAERS ID: |
935350 (history) |
| Form: |
Version 2.0 |
| Age: |
81.0 |
| Sex: |
Male |
| Location: |
Texas |
| Vaccinated: | 2020-12-31 |
| Onset: | 2021-01-02 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
037K20A / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: 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: 2021-01-06
Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 4 days
Extended hospital stay? No
Previous Vaccinations:
Other Medications: Symbicort 160/4.5 mcg/act inhaler Dilitiazem ER 360mg PO daily Eliquis 5mg PO twice a day Furosemide 20mg PO daily Losartan 100mg PO daily KCL 10mEq ER PO daily Ranitidine 150mg PO Ventolin HFA 0.09mg/1ACT 2 puffs every 4 hours as needed Me
Current Illness: Dyspnea, Shortness of breath
Preexisting Conditions: Paroxysmal atrial fibrillation Hypertension Chronic iron deficiency anemia Congestive heart failure with chronic diastolic
Allergies: No known allergies
Diagnostic Lab Data:
CDC Split Type:
Write-up: Patient was found unresponsive at home with SpO2 20% 1/2/2021 |
