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This is VAERS ID 1038658

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1038658
VAERS Form:2
Age:86.0
Sex:Female
Location:D.C.
Vaccinated:2021-02-01
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / UNK LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Aphasia, Death, Dyskinesia, Gait inability, Decreased appetite, Oxygen therapy, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-08
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: atenolol, docusate, calcium/vitamin D, furosemide, tamoxifen, multivitamin, trazodone, vitamin b12, vitron C
Current Illness: ankle/leg wound healing and being treated topically
Preexisting Conditions: history of TIA, breast neoplasm, dementia
Allergies: none
Diagnostic Lab Data: Unclear if the Moderna vaccine was #1 or #2. Vaccination form states is was vaccine #1. But patient checked the box that she had received a vaccine in the past 2-8 weeks on the form. Patient had gone to hospital around 1/4/2021 for fever and had a negative covid test per nursing notes in chart.
CDC 'Split Type':

Write-up: 86yo female alert, stable with ankle abrasion eating 100% prior to vaccine in assisted living facility. On 2/1/2021, received Moderna vaccine. Starting thereafter, eating 50% on 2/2/21. Temperature was 98 tympanic. On 2/3, the leg abrasion started having moderate bleeding. On 2/4, the caregiver noted patient "not looking good, unable to talk, arms moving aimlessly, grasping". BP 95/41, temperature 98, oxygen on room air 92-93%. POA did not want hospital transfer. 2/5 Hospice started, oxygen given, morphine given. 2/5-2/8 comfort care given, patient responsive to tactile stimuli, resting, not taking oral medications or food. 2/8/2021 patient expired.


Changed on 5/7/2021

VAERS ID: 1038658 Before After
VAERS Form:2
Age:86.0
Sex:Female
Location:D.C.
Vaccinated:2021-02-01
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / UNK LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Aphasia, Death, Dyskinesia, Gait inability, Decreased appetite, Oxygen therapy, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-08
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: atenolol, docusate, calcium/vitamin D, furosemide, tamoxifen, multivitamin, trazodone, vitamin b12, vitron C
Current Illness: ankle/leg wound healing and being treated topically
Preexisting Conditions: history of TIA, breast neoplasm, dementia
Allergies: none none
Diagnostic Lab Data: Unclear if the Moderna vaccine was #1 or #2. Vaccination form states is was vaccine #1. But patient checked the box that she had received a vaccine in the past 2-8 weeks on the form. Patient had gone to hospital around 1/4/2021 for fever and had a negative covid test per nursing notes in chart.
CDC 'Split Type':

Write-up: 86yo female alert, stable with ankle abrasion eating 100% prior to vaccine in assisted living facility. On 2/1/2021, received Moderna vaccine. Starting thereafter, eating 50% on 2/2/21. Temperature was 98 tympanic. On 2/3, the leg abrasion started having moderate bleeding. On 2/4, the caregiver noted patient "not looking good, unable to talk, arms moving aimlessly, grasping". BP 95/41, temperature 98, oxygen on room air 92-93%. POA did not want hospital transfer. 2/5 Hospice started, oxygen given, morphine given. 2/5-2/8 comfort care given, patient responsive to tactile stimuli, resting, not taking oral medications or food. 2/8/2021 patient expired.


Changed on 5/14/2021

VAERS ID: 1038658 Before After
VAERS Form:2
Age:86.0
Sex:Female
Location:D.C.
Vaccinated:2021-02-01
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 027L20A / UNK LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Aphasia, Death, Dyskinesia, Gait inability, Decreased appetite, Oxygen therapy, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-08
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: atenolol, docusate, calcium/vitamin D, furosemide, tamoxifen, multivitamin, trazodone, vitamin b12, vitron C
Current Illness: ankle/leg wound healing and being treated topically
Preexisting Conditions: history of TIA, breast neoplasm, dementia
Allergies: none none
Diagnostic Lab Data: Unclear if the Moderna vaccine was #1 or #2. Vaccination form states is was vaccine #1. But patient checked the box that she had received a vaccine in the past 2-8 weeks on the form. Patient had gone to hospital around 1/4/2021 for fever and had a negative covid test per nursing notes in chart.
CDC 'Split Type':

Write-up: 86yo female alert, stable with ankle abrasion eating 100% prior to vaccine in assisted living facility. On 2/1/2021, received Moderna vaccine. Starting thereafter, eating 50% on 2/2/21. Temperature was 98 tympanic. On 2/3, the leg abrasion started having moderate bleeding. On 2/4, the caregiver noted patient "not looking good, unable to talk, arms moving aimlessly, grasping". BP 95/41, temperature 98, oxygen on room air 92-93%. POA did not want hospital transfer. 2/5 Hospice started, oxygen given, morphine given. 2/5-2/8 comfort care given, patient responsive to tactile stimuli, resting, not taking oral medications or food. 2/8/2021 patient expired.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1038658&WAYBACKHISTORY=ON

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