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From the 11/19/2021 release of VAERS data:

This is VAERS ID 958745

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Case Details

VAERS ID: 958745 (history)  
Form: Version 2.0  
Age: 73.0  
Sex: Male  
Location: Colorado  
Vaccinated:2021-01-12
Onset:2021-01-14
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 025J20-2A / 1 LA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Asthenia, Fall, Pulse absent, Pyrexia, Skin warm, Unresponsive to stimuli
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hypotonic-hyporesponsive episode (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-16
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Divalproex Sodium Tab DR 250mg and 500mg, Lexapro 20mg, Quetiapine Fumarate 200mg tab, Senna 8.6 mg, Latanoprost drops,
Current Illness: Hx of TBI and schizophrenia with worsening behaviors over the past few months including refusing care including meals and medications and striking out with care. Resident had a fall on 1/14/2021. Resident received treatment for a UTI with Keflex for 7 days starting 12/6/2020.
Preexisting Conditions: Traumatic Brain Injury, Shizophrenia, hydrocephalus, hemiplegia following cerebrovascular disease affecting right side, aphasia, reduced mobility with use of w/c, repeated falls, dysphagia, major depression, thrombocytopenia, gluacoma, epilepsy.
Allergies: No Known Allergies
Diagnostic Lab Data: None
CDC Split Type:

Write-up: Resident was noted to have increase weakness on 1/15/2021. Resident was warm to touch with low grade fever of 99.3 F. Resident was up propelling self in w/c on 1/16/2021 he was pleasant, accepted medications and ate lunch. He was found slumped over in his w/c not responding and vital signs absent.


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