VAERS ID: |
992137 (history) |
Form: |
Version 2.0 |
Age: |
74.0 |
Sex: |
Male |
Location: |
South Carolina |
Vaccinated: | 2021-01-19 |
Onset: | 2021-01-25 |
Days after vaccination: | 6 |
Submitted: |
0000-00-00 |
Entered: |
2021-02-01 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
012L20A / 1 |
LA / IM |
Administered by: Private Purchased by: ? Symptoms: Bradycardia,
Cardio-respiratory arrest,
Death,
Diarrhoea haemorrhagic,
Hyporesponsive to stimuli,
Hypotension,
Mechanical ventilation SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Haemorrhage terms (excl laboratory terms) (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Pseudomembranous colitis (broad), Gastrointestinal haemorrhage (narrow), Acute central respiratory depression (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Ischaemic colitis (broad), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-31
Days after onset: 6
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 5 days
Extended hospital stay? No
Previous Vaccinations: Other Medications: oxymorphone ,mertazapine,medical marijuana , duloxetine , lisinopril , monolucast, hydocortisone, simvastatin amlodipine famotidine Current Illness: Preexisting Conditions: pan-hypo pituitarism, hypertension, hyperlipidemia chronic pain sleep apnea Allergies: Diagnostic Lab Data: See hospital record CDC Split Type:
Write-up: 6 days after vaccine developed bloody diarrhea. Thought to have ischemic colitis but negative evaluation. became hypotensive bradycardic placed on ventilator. Subsequently was poorly responsive and eventually coded once more and succumbed |