Adverse Event Reporting

VAERS ID	919537
Gender	Female
Age	96
StateCode	MN
Pharmaceutical Company	MODERNA
Lot Number	026L20A
Number of vaccinations	1
Vaccinated	2021-01-03
Onset	2021-01-03
Condition	Died

Symptoms

• Pulse absent

Current Illness

Resident had suspected vasovagal episode with drop in O2 saturation.

Preexisting Conditions

ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE RHEUMATOID ARTHRITIS, UNSPECIFIED ANEMIA, UNSPECIFIED HYPOTHYROIDISM, UNSPECIFIED CACHEXIA ESSENTIAL (PRIMARY) HYPERTENSION DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE AGE-RELATED PHYSICAL DEBILITY OTHER CHRONIC PAIN DILATED CARDIOMYOPATHY ERYTHEMATOUS CONDITION, UNSPECIFIED UNSPECIFIED OSTEOARTHRITIS, UNSPECIFIED SITE PRIMARY GENERALIZED (OSTEO)ARTHRITIS OTHER SPONDYLOSIS WITH RADICULOPATHY, LUMBAR REGION HYPERKALEMIA OTHER INTERVERTEBRAL DISC DEGENERATION, LUMBAR REGION AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL FRACTURE CERVICALGIA OTHER BIOMECHANICAL LESIONS OF LUMBAR REGION     BILATERAL PRIMARY OSTEOARTHRITIS OF KNEE LOCALIZED EDEMA HYPO-OSMOLALITY AND HYPONATREMIA OTHER SPECIFIED DISORDERS OF BONE DENSITY AND STRUCTURE, UNSPECIFIED SITE HISTORY OF FALLING WEAKNESS

Other Medications

Robitussin Cough+Chest Cong DM Liquid 5-100 MG/5ML (Dextromethorphan-guaiFENesin) Tylenol Extra Strength Tablet (Acetaminophen) amLODIPine Besylate Tablet 5 MG Morphine Solu Tab 2.5MG Capsaicin Cream 0.025 % Leflunomide Tablet 10 MG Levothy

Previous Vaccinations

Allergies

Celebrex and Tramadol

Laboratory Data

N/A.

Write-up

Resident exhibited no adverse events during 30 minute monitoring following vaccine administration.
Resident found without pulse at 1900.