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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1024539



Case Details

VAERS ID: 1024539 (history)  
Form: Version 2.0  
Age: 75.0  
Sex: Female  
Location: Arizona  
Vaccinated:2021-01-15
Onset:2021-01-28
   Days after vaccination:13
Submitted: 0000-00-00
Entered: 2021-02-11
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, COVID-19, Dyspnoea, Nausea, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died: 2021-02-08
   Days after onset: 11
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 8 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: allopurinol, citalopram, sodium bicarb., furosemide, ascorbic acid, folic acid, pravastatin, vitamin D2, levothyroxine, potassium chloride, calcium carbonate, b complex, omega 3s, prednisone, levocetirizine, tumeric, krill oil, metoprolol
Current Illness: shoulder pain, dermatitis, chronic kidney disease, edema, gerd, venous insufficiency, hypertension, RA, hypothyroidism, osteoporosis, depression, radiculopathy, rosacea.
Preexisting Conditions:
Allergies: alupent, coumadin, cephalexin, saccharin, gabapentin, codeine sulfate, sulpher, onion, perfumes and fragrances, adhesive.
Diagnostic Lab Data:
CDC Split Type:

Write-up: patient tested positive for covid on 1/29/21. was hospitalized on 2/8/21 for shortness of breath, generalized weakness, nausea.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1024539

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