VAERS ID: |
1078352 (history) |
Form: |
Version 2.0 |
Age: |
18.0 |
Sex: |
Male |
Location: |
Illinois |
Vaccinated: | 2021-03-02 |
Onset: | 2021-03-05 |
Days after vaccination: | 3 |
Submitted: |
0000-00-00 |
Entered: |
2021-03-06 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
010A21A / 1 |
LA / IM |
Administered by: Private Purchased by: ? Symptoms: Chest pain,
Death,
Fatigue,
Headache,
Pain,
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), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Hypoglycaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-03-05
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Other Medications: Current Illness: Preexisting Conditions: Allergies: Diagnostic Lab Data: Medical examiner report is pending. CDC Split Type:
Write-up: Developed fatigue, body aches, headache 1 day after vaccination on 3/3. The morning of 3/5 complained of chest pain. Took Tylenol at 8:30 am. At 10:30 am his family found him unresponsive. EMS was called and he was pronounced dead in the home. |