Adverse Event Reporting

VAERS ID 914473
Gender Female
Age 83
StateCode MO
Pharmaceutical Company MODERNA
Lot Number 025J20A
Number of vaccinations 1
Vaccinated 2020-12-28
Onset 2020-12-29
Condition Permanent Disability
  • Fatigue
  • Pyrexia
  • Tremor
  • Asthenia
  • Hypertension
  • Rash
  • Decreased appetite
  • Chest X-ray
  • Laboratory test
  • Mental status changes
  • Facial paralysis
  • Rash macular
  • Livedo reticularis
  • Speech disorder
  • Computerised tomogram head
  • Cognitive disorder
  • Depressed level of consciousness

Current Illness

COVID-19 positive

Preexisting Conditions

hypertension, hypokalemia, malignant neoplasm, tremor,

Other Medications

Eliquis, carbidopa-levidopa, Cardizem, Comtan, gabapentin, metoprolol, omeprazole, potassium citrate

Previous Vaccinations


Cipro, Levaquin, topiramate

Laboratory Data

Lab, Chest x-ray, Head CT, IVF


Weakness, fatigue, decreased appetite, upper extremity shaking, sternal red blotchy rash, decreased mental status, non-verbal, decreased level of conscious, mottling, left side facial droop, hypertensive, fever, unable to follow commands