VAERS ID: |
1187918 (history) |
Form: |
Version 2.0 |
Age: |
15.0 |
Sex: |
Female |
Location: |
New Hampshire |
Vaccinated: |
0000-00-00 |
Onset: |
2021-04-05 |
Submitted: |
0000-00-00 |
Entered: |
2021-04-09 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA |
- / UNK |
- / - |
Administered by: Private Purchased by: ? Symptoms: Cardiac arrest, Intensive care SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Noninfectious myocarditis/pericarditis (broad) Life Threatening? No Birth Defect? No Died? Yes
Date died: 2021-04-06
Days after onset: 1 Permanent Disability? No Recovered? No Office Visit? No ER Visit? No ER or Doctor Visit? No Hospitalized? No Previous Vaccinations: Other Medications: levothyroxine Current Illness: Preexisting Conditions: Trisomey 21, Atrioventricular canal s/p repair, hypothyroidism, asthma, obstructive sleep apnea, cervical spine instability, hypotonia, scoliosis, feeding difficulties, renal dysplasia, autism, chronic constipation, bronchopulmonary dysplasia, mixed conductive and sensorineural hearing loss, binocular vision disorder, gastroesophgeal reflux, Allergies: Cefdinir, Sulfa, Ex-Lax, NSAIDS Diagnostic Lab Data: CDC Split Type: Write-up: I do not know the exact date of the first or second Moderna Vaccine. I am the PICU attending who cared for the patient after her cardiac arrest which we believe was about 3-4 days after her second Moderna Vaccine |