National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 4/30/2021 release of VAERS data:

This is VAERS ID 1002636



Case Details

VAERS ID: 1002636 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: Washington  
Vaccinated:2020-12-28
Onset:2021-01-17
   Days after vaccination:20
Submitted: 0000-00-00
Entered: 2021-02-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20A / 1 LA / IM

Administered by: Other       Purchased by: ?
Symptoms: Angiogram, Angiogram cerebral abnormal, Aphasia, Cerebral artery occlusion, Computerised tomogram abnormal, Computerised tomogram head, Death, Fall, Movement disorder, NIH stroke scale score increased, Nervous system disorder, Thrombectomy
SMQs:, Ischaemic central nervous system vascular conditions (narrow), Dementia (broad), Embolic and thrombotic events, arterial (narrow), Embolic and thrombotic events, vessel type unspecified and mixed arterial and venous (narrow), Akathisia (broad), Dyskinesia (broad), Dystonia (broad), Parkinson-like events (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Accidents and injuries (narrow), Conditions associated with central nervous system haemorrhages and cerebrovascular accidents (broad)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-01-23
   Days after onset: 6
Permanent Disability? Yes
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: ASA 81 mg, allopurinol, potassium chloride, furosemide, diltiazem, metoprolol, tiotropium, albuterol, diclofenac gel topical
Current Illness: None - had exposure to COVID19 + case on 12/18/2020 but tested negative.
Preexisting Conditions: CHF, HTN, hyperlipidemia, atrial fibrillation, COPD (O2 dependent) , CKD Stage 4, type 2 diabetes (diet controlled).
Allergies: Oxycodone, Percodan, atenolol, PCN VK
Diagnostic Lab Data: CT 1/17/21 (no acute hemorrhage but mild hypodensity of greater than 1/3 of the MCA territory) and CT Angiogram on 1/17/21 ( distal L M1/M2 occulsion).
CDC Split Type:

Write-up: On 1/17/2021 patient woke and began her day as usual, was found down by family member 1 hour later conscious but unable to speak and unable to move her R side. She was admitted to the hospital - Initial NIHSS was 26 and CT imaging showed no acute hemorrhage but mild hypodensity of greater than 1/3 of the MCA territory (TPA not recommended). CTA did show distal L M1/M2 occulsion and she was transferred to larger facility for thrombectomy. Unfortunately the patient had persistent severe neurological deficits after thrombectomy. Was discharged home on hospice care and expired on 1/23/21.


New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=1002636


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166