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This is VAERS ID 1040170

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1040170
VAERS Form:2
Age:37.0
Sex:Female
Location:Oregon
Vaccinated:2021-02-06
Onset:2021-02-13
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood creatinine increased, Blood glucose decreased, Blood lactic acid increased, Blood magnesium increased, Blood potassium increased, Cardiac arrest, Cyanosis, Erythema, Pain, Peripheral coldness, Pyrexia, Respiration abnormal, Resuscitation, White blood cell count increased, Agonal rhythm, Troponin increased, Analgesic drug level therapeutic, Abnormal behaviour, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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: Tylenol, calcium citrate, antifungal cream to stoma, Bisacodyl suppository as needed, calcium citrate, tube feeds, lansoprazole, reglan, centrum multivitamin, polyethylene glycol every other day, norgestimate-estradiol daily, trazodone, tiz
Current Illness: none. she had been very stable on her medication regimen and in her living arrangement for years. No issues whatsoever. Caregivers had been caring for her for as long as 19 years.
Preexisting Conditions: cerebral palsy, spastic quadriplegia, dysphagia with g-tube in place, developmental delay - minimally verbal, tube feed dependency, intrathecal baclofen pump, osteoporosis, white coat hypertension, candidiasis of skin..
Allergies: reclast - caused fever in 2014, leading to hospitalization, seizure from the fever.. tegretol (no reaction noted)
Diagnostic Lab Data: labs from ER on 2/13/2021 - trop 2.49; WBC 55, lactate 21.5, creat 1.29, postassium 6.2, mag 3.4, glucose 57, AST 3024, ALT 3088, acetaminophen < 10, salicylate < 1.
CDC 'Split Type':

Write-up: Received vaccine on 2/6/2021. was a bit off all week per caregivers - low grade temp and reporting pain which they treated with Tylenol. She was pretty much herself on morning of 2/13/2021 - got up, had shower. caregivers noted her extremities were cool and face was red. temp was 97.4. She was placed in wheelchair with book in the living room. caregivers noted she was not turning pages of the book as she usually would. She was tracking, so they don''t think she had a seizure. Caregiver moved her back to bed with blanket and noted that her lips were blue and at that point called 911. She was found with agonal breathing, CPR started, intubated by EMS, taken to the ER and diagnosed with cardiac arrest upon arrival. CPR was continued until family could be reached and decision was made to stop resuscitation.


Changed on 5/7/2021

VAERS ID: 1040170 Before After
VAERS Form:2
Age:37.0
Sex:Female
Location:Oregon
Vaccinated:2021-02-06
Onset:2021-02-13
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood creatinine increased, Blood glucose decreased, Blood lactic acid increased, Blood magnesium increased, Blood potassium increased, Cardiac arrest, Cyanosis, Erythema, Pain, Peripheral coldness, Pyrexia, Respiration abnormal, Resuscitation, White blood cell count increased, Agonal rhythm, Troponin increased, Analgesic drug level therapeutic, Abnormal behaviour, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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: Tylenol, calcium citrate, antifungal cream to stoma, Bisacodyl suppository as needed, calcium citrate, tube feeds, lansoprazole, reglan, centrum multivitamin, polyethylene glycol every other day, norgestimate-estradiol daily, trazodone, tiz
Current Illness: none. she had been very stable on her medication regimen and in her living arrangement for years. No issues whatsoever. Caregivers had been caring for her for as long as 19 years.
Preexisting Conditions: cerebral palsy, spastic quadriplegia, dysphagia with g-tube in place, developmental delay - minimally verbal, tube feed dependency, intrathecal baclofen pump, osteoporosis, white coat hypertension, candidiasis of skin..
Allergies: reclast - caused fever in 2014, leading to hospitalization, seizure from the fever.. tegretol (no reaction noted) noted)
Diagnostic Lab Data: labs from ER on 2/13/2021 - trop 2.49; WBC 55, lactate 21.5, creat 1.29, postassium 6.2, mag 3.4, glucose 57, AST 3024, ALT 3088, acetaminophen < 10, salicylate < 1.
CDC 'Split Type':

Write-up: Received vaccine on 2/6/2021. was a bit off all week per caregivers - low grade temp and reporting pain which they treated with Tylenol. She was pretty much herself on morning of 2/13/2021 - got up, had shower. caregivers noted her extremities were cool and face was red. temp was 97.4. She was placed in wheelchair with book in the living room. caregivers noted she was not turning pages of the book as she usually would. She was tracking, so they don''t think she had a seizure. Caregiver moved her back to bed with blanket and noted that her lips were blue and at that point called 911. She was found with agonal breathing, CPR started, intubated by EMS, taken to the ER and diagnosed with cardiac arrest upon arrival. CPR was continued until family could be reached and decision was made to stop resuscitation.


Changed on 5/14/2021

VAERS ID: 1040170 Before After
VAERS Form:2
Age:37.0
Sex:Female
Location:Oregon
Vaccinated:2021-02-06
Onset:2021-02-13
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Alanine aminotransferase increased, Aspartate aminotransferase increased, Blood creatinine increased, Blood glucose decreased, Blood lactic acid increased, Blood magnesium increased, Blood potassium increased, Cardiac arrest, Cyanosis, Erythema, Pain, Peripheral coldness, Pyrexia, Respiration abnormal, Resuscitation, White blood cell count increased, Agonal rhythm, Troponin increased, Analgesic drug level therapeutic, Abnormal behaviour, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-13
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: Tylenol, calcium citrate, antifungal cream to stoma, Bisacodyl suppository as needed, calcium citrate, tube feeds, lansoprazole, reglan, centrum multivitamin, polyethylene glycol every other day, norgestimate-estradiol daily, trazodone, tiz
Current Illness: none. she had been very stable on her medication regimen and in her living arrangement for years. No issues whatsoever. Caregivers had been caring for her for as long as 19 years.
Preexisting Conditions: cerebral palsy, spastic quadriplegia, dysphagia with g-tube in place, developmental delay - minimally verbal, tube feed dependency, intrathecal baclofen pump, osteoporosis, white coat hypertension, candidiasis of skin..
Allergies: reclast - caused fever in 2014, leading to hospitalization, seizure from the fever.. tegretol (no reaction noted) noted)
Diagnostic Lab Data: labs from ER on 2/13/2021 - trop 2.49; WBC 55, lactate 21.5, creat 1.29, postassium 6.2, mag 3.4, glucose 57, AST 3024, ALT 3088, acetaminophen < 10, salicylate < 1.
CDC 'Split Type':

Write-up: Received vaccine on 2/6/2021. was a bit off all week per caregivers - low grade temp and reporting pain which they treated with Tylenol. She was pretty much herself on morning of 2/13/2021 - got up, had shower. caregivers noted her extremities were cool and face was red. temp was 97.4. She was placed in wheelchair with book in the living room. caregivers noted she was not turning pages of the book as she usually would. She was tracking, so they don''t think she had a seizure. Caregiver moved her back to bed with blanket and noted that her lips were blue and at that point called 911. She was found with agonal breathing, CPR started, intubated by EMS, taken to the ER and diagnosed with cardiac arrest upon arrival. CPR was continued until family could be reached and decision was made to stop resuscitation.

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