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This is VAERS ID 1038635

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1038635
VAERS Form:2
Age:97.0
Sex:Female
Location:South Dakota
Vaccinated:2021-02-05
Onset:2021-02-06
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / UN

Administered by: Unknown      Purchased by: ??
Symptoms: Arrhythmia, Cardiac arrest, Death, Dementia, Fall, Hip arthroplasty, Hip fracture, Hypothyroidism

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-07
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg enteric-coated q a.m. Plavix 75 mg po at bedtime Iron, Ferrex-150 25/1/150 tid with meals Folic acid 1 mg bid Metoprolol tartrate 25 mg bid MiraLAX 8.5 gm daily Synthroid 100 mcg a day Tamsulosin 0
Current Illness: A fall occurred on the day after vaccination; she fractured her hip in this fall. The physician reports she went into sudden and unexpected cardiac arrest during surgery and died. Patient had COVID-19 approx 11/06/2020. Possible urinary tract infection on admit for the fall
Preexisting Conditions: History of breast cancer (bilateral; patient is post-bilateral masectomy) Hypothyroid Dementia ("always confused about time and place") Recurrent urinary tract infections The patient was admitted August 2020 with suspected seizure but this was attributed to UTI and/or dementia) Hypertension Diffuse Arthritis Resident of assisted living facility
Allergies: Erythromycin Codeine
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The patient fell the day after receiving the Moderna COVID-19 vaccine. She broke her hip in this fall. During surgery to correct the broken hip, she went in to sudden and unexpected cardiac arrest. The anesthetist did not notice any ST changes or A fib; dysrhythmia was very unexpected. The patient had a DNR. She died at 13:00 on 02/07/2021. Causes of death are listed as 1. Cardiac Arrest 2. Recent hip fracture with hip placement 3. History of Breast Cancer 4. Hypothyroid and 5. Dementia


Changed on 5/7/2021

VAERS ID: 1038635 Before After
VAERS Form:2
Age:97.0
Sex:Female
Location:South Dakota
Vaccinated:2021-02-05
Onset:2021-02-06
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / UN

Administered by: Unknown      Purchased by: ??
Symptoms: Arrhythmia, Cardiac arrest, Death, Dementia, Fall, Hip arthroplasty, Hip fracture, Hypothyroidism

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-07
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg enteric-coated q a.m. Plavix 75 mg po at bedtime Iron, Ferrex-150 25/1/150 tid with meals Folic acid 1 mg bid Metoprolol tartrate 25 mg bid MiraLAX 8.5 gm daily Synthroid 100 mcg a day Tamsulosin 0
Current Illness: A fall occurred on the day after vaccination; she fractured her hip in this fall. The physician reports she went into sudden and unexpected cardiac arrest during surgery and died. Patient had COVID-19 approx 11/06/2020. Possible urinary tract infection on admit for the fall
Preexisting Conditions: History of breast cancer (bilateral; patient is post-bilateral masectomy) Hypothyroid Dementia ("always confused about time and place") Recurrent urinary tract infections The patient was admitted August 2020 with suspected seizure but this was attributed to UTI and/or dementia) Hypertension Diffuse Arthritis Resident of assisted living facility
Allergies: Erythromycin Codeine Codeine
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The patient fell the day after receiving the Moderna COVID-19 vaccine. She broke her hip in this fall. During surgery to correct the broken hip, she went in to sudden and unexpected cardiac arrest. The anesthetist did not notice any ST changes or A fib; dysrhythmia was very unexpected. The patient had a DNR. She died at 13:00 on 02/07/2021. Causes of death are listed as 1. Cardiac Arrest 2. Recent hip fracture with hip placement 3. History of Breast Cancer 4. Hypothyroid and 5. Dementia


Changed on 5/14/2021

VAERS ID: 1038635 Before After
VAERS Form:2
Age:97.0
Sex:Female
Location:South Dakota
Vaccinated:2021-02-05
Onset:2021-02-06
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / UN

Administered by: Unknown      Purchased by: ??
Symptoms: Arrhythmia, Cardiac arrest, Death, Dementia, Fall, Hip arthroplasty, Hip fracture, Hypothyroidism

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-07
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin 81 mg enteric-coated q a.m. Plavix 75 mg po at bedtime Iron, Ferrex-150 25/1/150 tid with meals Folic acid 1 mg bid Metoprolol tartrate 25 mg bid MiraLAX 8.5 gm daily Synthroid 100 mcg a day Tamsulosin 0
Current Illness: A fall occurred on the day after vaccination; she fractured her hip in this fall. The physician reports she went into sudden and unexpected cardiac arrest during surgery and died. Patient had COVID-19 approx 11/06/2020. Possible urinary tract infection on admit for the fall
Preexisting Conditions: History of breast cancer (bilateral; patient is post-bilateral masectomy) Hypothyroid Dementia ("always confused about time and place") Recurrent urinary tract infections The patient was admitted August 2020 with suspected seizure but this was attributed to UTI and/or dementia) Hypertension Diffuse Arthritis Resident of assisted living facility
Allergies: Erythromycin Codeine Codeine
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The patient fell the day after receiving the Moderna COVID-19 vaccine. She broke her hip in this fall. During surgery to correct the broken hip, she went in to sudden and unexpected cardiac arrest. The anesthetist did not notice any ST changes or A fib; dysrhythmia was very unexpected. The patient had a DNR. She died at 13:00 on 02/07/2021. Causes of death are listed as 1. Cardiac Arrest 2. Recent hip fracture with hip placement 3. History of Breast Cancer 4. Hypothyroid and 5. Dementia

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