Adverse Event Reporting
| VAERS ID | 924664 |
|---|---|
| Gender | Female |
| Age | 92 |
| StateCode | HI |
| Pharmaceutical Company | MODERNA |
| Lot Number | O11L20A |
| Number of vaccinations | 1 |
| Vaccinated | 2021-01-02 |
| Onset | 2021-01-05 |
| Condition | Died |
Symptoms
- Unresponsive to stimuli
- Computerised tomogram abnormal
- X-ray abnormal
- Death
- Pulmonary oedema
- Intracranial aneurysm
Current Illness
none
Preexisting Conditions
history of stroke, hyperlipidemia, dementia, GERD, and macular degeneration
Other Medications
Metoprolol succ ER 50mg 1 tab PO daily Omeprazole DR 20mg 1 cap PO daily Amlodipine besylate 5mg 1 tab PO daily Aspirin 81mg 1 tab PO daily Carbamazepine ER 100mg 1 tab PO TID Docusate 100mg 1 cap PO daily Multivitamin 1 tab PO daily Olmesa
Previous Vaccinations
Allergies
Hydrochlorothiazide
Laboratory Data
CT scan, X ray 1/5/2021
Write-up
At approximately, 1855, I was alerted by caregiver, resident was not responding.
Per caregiver, she was doing her rounds and found resident in bed, unresponsive, mouth open, observed gurgling noises and tongue hanging out of mouth.
This primary caregiver observed resident at baseline and ambulating after dinner at approximately, 1800 less than an hour prior to incident.
This PCG called 911 for EMS and gave report of incident.
Resident was taken to Medical Center Emergency Department.
At ER, CT scan and X-ray was performed.
Per report from ER RN, CT scan and x-ray revealed an intracranial aneurysm and fluid in the lungs.
Per RN, resident was still unresponsive and was admitted to Medical Center for observation and comfort measures.
This primary caregiver reported to RN, resident recently received the first dose of COVID-19 vaccine on 1/2/21.
Primary caregiver received a call from Castle RN at 0700, resident expired at 0615.