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This is VAERS ID 1031544

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1031544
VAERS Form:2
Age:90.0
Sex:Female
Location:Iowa
Vaccinated:2021-02-11
Onset:2021-02-14
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Confusional state, Death, Loss of consciousness, Subdural haemorrhage, Imaging procedure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Alendronate 70mg tab Clopidogrel 75mg tab Donepezil 5mg tab Hydrochlorothiazide 12.5mg Lactobacillius tabs Levothyroxine 75mcg tab Lostartan 50mg tab Citrucel PO Metoprolol tartrate 25mg tab Pantoprazole 40mg tab Rosuvastsatin 10mg tab Tria
Current Illness: Diagnosed with subdural hemorrhage at time of incident
Preexisting Conditions: Hyperlipideia Hx stroke Hypothyroidism Gastric ulcer HTN Stress incontinence Uterine cancer Late onset Alzheimer''s Osteopenia Osteoarthritis Varicose veins in legs Venous insufficiency Adjustment disorder with anxiety
Allergies: Ibandronic acid- nausea and vomiting Sulfa- nausea and vomiting Risedronate Environmental- pollen Nitrofurantoin macro Ezetimibe-Simvastatin Codeine- anxiety Erythromycin- nausea
Diagnostic Lab Data: Imaging 2/13-2/14
CDC 'Split Type':

Write-up: Patient family had been noticing onset confusion for a few weeks prior to vaccine and event. Patient was taken to ED when found unconscious and died of a subdural hemorrhage a few days after vaccine clinic at retirement home.


Changed on 5/7/2021

VAERS ID: 1031544 Before After
VAERS Form:2
Age:90.0
Sex:Female
Location:Iowa
Vaccinated:2021-02-11
Onset:2021-02-14
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Confusional state, Death, Loss of consciousness, Subdural haemorrhage, Imaging procedure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Alendronate 70mg tab Clopidogrel 75mg tab Donepezil 5mg tab Hydrochlorothiazide 12.5mg Lactobacillius tabs Levothyroxine 75mcg tab Lostartan 50mg tab Citrucel PO Metoprolol tartrate 25mg tab Pantoprazole 40mg tab Rosuvastsatin 10mg tab Tria
Current Illness: Diagnosed with subdural hemorrhage at time of incident
Preexisting Conditions: Hyperlipideia Hx stroke Hypothyroidism Gastric ulcer HTN Stress incontinence Uterine cancer Late onset Alzheimer''s Osteopenia Osteoarthritis Varicose veins in legs Venous insufficiency Adjustment disorder with anxiety
Allergies: Ibandronic acid- nausea and vomiting Sulfa- nausea and vomiting Risedronate Environmental- pollen Nitrofurantoin macro Ezetimibe-Simvastatin Codeine- anxiety Erythromycin- nausea nausea
Diagnostic Lab Data: Imaging 2/13-2/14
CDC 'Split Type':

Write-up: Patient family had been noticing onset confusion for a few weeks prior to vaccine and event. Patient was taken to ED when found unconscious and died of a subdural hemorrhage a few days after vaccine clinic at retirement home.


Changed on 5/14/2021

VAERS ID: 1031544 Before After
VAERS Form:2
Age:90.0
Sex:Female
Location:Iowa
Vaccinated:2021-02-11
Onset:2021-02-14
Submitted:0000-00-00
Entered:2021-02-15
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 022M20A / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Confusional state, Death, Loss of consciousness, Subdural haemorrhage, Imaging procedure

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-14
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Alendronate 70mg tab Clopidogrel 75mg tab Donepezil 5mg tab Hydrochlorothiazide 12.5mg Lactobacillius tabs Levothyroxine 75mcg tab Lostartan 50mg tab Citrucel PO Metoprolol tartrate 25mg tab Pantoprazole 40mg tab Rosuvastsatin 10mg tab Tria
Current Illness: Diagnosed with subdural hemorrhage at time of incident
Preexisting Conditions: Hyperlipideia Hx stroke Hypothyroidism Gastric ulcer HTN Stress incontinence Uterine cancer Late onset Alzheimer''s Osteopenia Osteoarthritis Varicose veins in legs Venous insufficiency Adjustment disorder with anxiety
Allergies: Ibandronic acid- nausea and vomiting Sulfa- nausea and vomiting Risedronate Environmental- pollen Nitrofurantoin macro Ezetimibe-Simvastatin Codeine- anxiety Erythromycin- nausea nausea
Diagnostic Lab Data: Imaging 2/13-2/14
CDC 'Split Type':

Write-up: Patient family had been noticing onset confusion for a few weeks prior to vaccine and event. Patient was taken to ED when found unconscious and died of a subdural hemorrhage a few days after vaccine clinic at retirement home.

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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1031544&WAYBACKHISTORY=ON

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