| Days after vaccination:||20
|Vaccination / Manufacturer
||Lot / Dose
||Site / Route|
|COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA
||025J20A / 1
||LA / IM
Administered by: Other Purchased by: ?
Angiogram cerebral abnormal,
Cerebral artery occlusion,
Computerised tomogram abnormal,
Computerised tomogram head,
NIH stroke scale score increased,
Nervous system disorder,
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
Date died: 2021-01-23
Days after onset: 6
Permanent Disability? Yes
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 3 days
Extended hospital stay? No
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.