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From the 6/11/2021 release of VAERS data:

This is VAERS ID 1034349



Case Details

VAERS ID: 1034349 (history)  
Form: Version 2.0  
Age: 90.0  
Sex: Female  
Location: California  
Vaccinated:2021-02-10
Onset:2021-02-12
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-02-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 016M20A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Activated partial thromboplastin time, Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase increased, Basophil count normal, Basophil percentage, Blood albumin normal, Blood alkaline phosphatase normal, Blood bicarbonate decreased, Blood bicarbonate increased, Blood bilirubin normal, Blood calcium normal, Blood chloride increased, Blood chloride normal, Blood creatinine increased, Blood gases abnormal, Blood glucose increased, Blood magnesium increased, Blood methaemoglobin, Blood potassium normal, Blood sodium decreased, Blood urea normal, Carbon dioxide decreased, Carboxyhaemoglobin decreased, Confusional state, Death, Differential white blood cell count, Electrocardiogram normal, Eosinophil count normal, Eosinophil percentage, Fibrin D dimer increased, Fraction of inspired oxygen, Full blood count, Glomerular filtration rate decreased, Haematocrit decreased, Haemoglobin decreased, Hypotension, Influenza A virus test negative, Influenza B virus test, International normalised ratio increased, Lymphocyte count, Lymphocyte percentage, Mean cell haemoglobin concentration normal, Mean cell haemoglobin normal, Mean cell volume normal, Mental status changes, Metabolic function test, Methaemoglobin urine absent, Monocyte count decreased, Monocyte percentage, N-terminal prohormone brain natriuretic peptide increased, Neutrophil count, Neutrophil percentage, Nucleated red cells, Oxygen saturation normal, PCO2 decreased, PO2 increased, Platelet count decreased, Protein total normal, Prothrombin time prolonged, Red blood cell count decreased, Red cell distribution width normal, Respiratory distress, SARS-CoV-2 test negative, Troponin I increased, White blood cell count normal, pH urine normal
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Cardiac failure (broad), Liver related investigations, signs and symptoms (narrow), Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (narrow), Asthma/bronchospasm (broad), Haematopoietic erythropenia (narrow), Haematopoietic leukopenia (narrow), Haematopoietic thrombocytopenia (narrow), Lactic acidosis (broad), Haemorrhage laboratory terms (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Systemic lupus erythematosus (broad), Myocardial infarction (narrow), Anticholinergic syndrome (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Acute central respiratory depression (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hyponatraemia/SIADH (narrow), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Tubulointerstitial diseases (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), Hypokalaemia (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine 2.5 mg BID Metformin 500 mg BID Losartan 100 mg qd Simvastatin 10 mg qd Levothyroxine 50 mcg qd torsemide 20 mg qd
Current Illness: Unknown
Preexisting Conditions: Congestive heart failure Hypertension Type 2 Diabetes Chronic venous insufficiency Hypothyroidisn Coronary artery disease Dyslipidemia
Allergies: None
Diagnostic Lab Data: BLOOD GAS, ARTERIAL Result Value Ref Range Puncture Site Right Radial Allen''s Test Pos pH Measured 7.111 (LL) 7.350 - 7.450 pCO2, Measured 27.9 (L) 35.0 - 45.0 mmHg PO2 Measured 143.9 (H) 80 - 100 mmHg Bicarbonate 8.7 (LL) 20.0 - 26.0 mmol/L Base Deficit 19.4 (H) 0.0 - 3.0 mmol/L Carboxyhemoglobin 0.2 (L) 0.5 - 1.5 % Methemoglobin 0.0 0.0 - 1.5 % O2 Saturation 98 94 - 99 % FiO2 60 COMPREHENSIVE METABOLIC PANEL W GFR Result Value Ref Range Sodium 131 (L) 136 - 145 mmol/L Potassium 4.7 3.5 - 5.1 mmol/L Chloride 100 98 - 107 mmol/L CO2 (Bicarbonate) 10 (LL) 21 - 32 mmol/L Anion Gap 21 (H) 3 - 12 mmol/L Glucose 488 (HH) 70 - 99 mg/dL BUN 25 6 - 25 mg/dL Creatinine 2.01 (H) 0.40 - 1.00 mg/dL GFR Est-Other 21 (L) $g60 See Cmnt GFR Est-African American 25 (L) $g60 See Cmnt Calcium 9.0 8.2 - 10.2 mg/dL Total Protein 6.6 6.4 - 8.2 g/dL Albumin 3.2 3.2 - 4.7 g/dL Total Bilirubin 1.1 0.1 - 1.3 mg/dL Alkaline Phosphatase 71 26 - 137 U/L AST 47 (H) 0 - 37 U/L ALT 36 15 - 65 U/L TROPONIN I Result Value Ref Range Troponin I 0.09 (H) 0.00 - 0.05 ng/mL N-TERM PRO-BRAIN NATRIURETIC PEPTIDE (PROBNP) Result Value Ref Range NT Pro BNP 1,580 0 - 1,800 pg/mL MAGNESIUM Result Value Ref Range Magnesium 2.6 (H) 1.5 - 2.5 mg/dL CBC WITH AUTOMATED DIFFERENTIAL Result Value Ref Range White Blood Cell Count 6.8 4.0 - 11.0 K/uL Red Blood Cell Count 3.37 (L) 3.90 - 5.40 M/uL Hemoglobin 9.9 (L) 11.7 - 15.5 g/dL Hematocrit 30.9 (L) 35.0 - 47.0 % MCV 92 80 - 100 fL MCH 29.4 27.0 - 33.0 pg MCHC 32.0 31.0 - 36.0 g/dL RDW 14.1 <16.4 % Platelet Count 144 (L) 150 - 400 K/uL Differential Type Automated Neutrophil % 72 % Lymphocyte % 25 % Monocyte % 3 % Eosinophil % 0 % Basophil % 0 % Abs. Neutrophil 4.8 2.0 - 8.0 K/uL Abs. Lymphocyte 1.7 1.0 - 5.1 K/uL Abs. Monocyte 0.2 0.0 - 0.8 K/uL Abs. Eosinophil 0.0 0.0 - 0.5 K/uL Abs. Basophil 0.0 0.0 - 0.2 K/uL NUCLEATED RBC AUTO 0.0 0.0 /100 WBC PROTHROMBIN TIME/INR Result Value Ref Range Prothrombin Time 16.1 (H) 12.1 - 14.7 sec INR 1.3 (H) 0.8 - 1.2 PARTIAL THROMBOPLASTIN TIME Result Value Ref Range PTT 26.3 23.3 - 36.2 sec D-DIMER,QUANTITATIVE Result Value Ref Range D Dimer, Quant 2.70 (H) <0.50 ug(FEU)/mL INFLUENZA A & B NAAT Result Value Ref Range INFLUENZA A RNA Not Detected Not Detected INFLUENZA B RNA Not Detected Not Detected CORONAVIRUS 2019 NAA(COVID-19,SARS2) Result Value Ref Range SARS-COV-2, NAA Not Detected Not Detected ECG interpretation : junctional rhythm, regular, no ST elevation or depressions, diffuse T wave flattending, no marked QT prolongation. Interpreted contemporaneously by me.
CDC Split Type:

Write-up: Patient awoke on 2/12/21 with altered mental status, confusion, respiratory distress, was taken to hospital by ambulance. Per ED notes from ED attending Pt presented with hypotension and respiratory distress. DNR status, patient given comfort measures and passed away in ED at 11:24 am on 2/12/21.


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