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This is VAERS ID 1041719

History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1041719
VAERS Form:2
Age:92.0
Sex:Female
Location:West Virginia
Vaccinated:2021-02-17
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
UNK: VACCINE NOT SPECIFIED (OTHER) / UNKNOWN MANUFACTURER 030M20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Arthralgia, Death, Fall, Pulse absent, Respiratory arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-17
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: Depakote, lasix, memantine, metoprolol, senna s, vit D3, miralax, xarelto, remeron
Current Illness: Resident slid out of recliner at 430pm on the date of vaccine and death. Denied pain and ROM was without issues. At 630pm she complained of right hip pain. Mobile xray was ordered. Resident passed in her bed after sleeping for 30 mins. Xray did not make it on time, therefore, unsure of fracture.
Preexisting Conditions: Dementia, PVD, Vit D deficiency, anxiety, HTN, Afib, postrial kyphosis, CHF, UTIs, Debility, sundowning, skin neoplasm left side of nose
Allergies: Fosomax
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt received moderna vaccine #2 at 1:30pm. No s/s of adverse reactions. Ate dinner at 4pm. She was in her room at 430pm and she slid out of her chair and was laying on her Right side. She reported she slid out of her chair because she needed to go urinate per staff. She denied pain. At 630p complained of right hip pain. mobile xray was ordered. At 825pm resident was sleeping x 30 mins in her bed when she was found to have no pulse or respirations. She ceased to breathe. Mobile xray did not make it on time.


Changed on 3/26/2021

VAERS ID: 1041719 Before After
VAERS Form:2
Age:92.0
Sex:Female
Location:West Virginia
Vaccinated:2021-02-17
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 LA / IM
UNK: VACCINE NOT SPECIFIED (OTHER) / UNKNOWN MANUFACTURER 030M20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Arthralgia, Death, Fall, Pulse absent, Respiratory arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-17
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: Depakote, lasix, memantine, metoprolol, senna s, vit D3, miralax, xarelto, remeron
Current Illness: Resident slid out of recliner at 430pm on the date of vaccine and death. Denied pain and ROM was without issues. At 630pm she complained of right hip pain. Mobile xray was ordered. Resident passed in her bed after sleeping for 30 mins. Xray did not make it on time, therefore, unsure of fracture.
Preexisting Conditions: Dementia, PVD, Vit D deficiency, anxiety, HTN, Afib, postrial kyphosis, CHF, UTIs, Debility, sundowning, skin neoplasm left side of nose
Allergies: Fosomax
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt received moderna vaccine #2 at 1:30pm. No s/s of adverse reactions. Ate dinner at 4pm. She was in her room at 430pm and she slid out of her chair and was laying on her Right side. She reported she slid out of her chair because she needed to go urinate per staff. She denied pain. At 630p complained of right hip pain. mobile xray was ordered. At 825pm resident was sleeping x 30 mins in her bed when she was found to have no pulse or respirations. She ceased to breathe. Mobile xray did not make it on time.


Changed on 5/7/2021

VAERS ID: 1041719 Before After
VAERS Form:2
Age:92.0
Sex:Female
Location:West Virginia
Vaccinated:2021-02-17
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Arthralgia, Death, Fall, Pulse absent, Respiratory arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-17
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: Depakote, lasix, memantine, metoprolol, senna s, vit D3, miralax, xarelto, remeron
Current Illness: Resident slid out of recliner at 430pm on the date of vaccine and death. Denied pain and ROM was without issues. At 630pm she complained of right hip pain. Mobile xray was ordered. Resident passed in her bed after sleeping for 30 mins. Xray did not make it on time, therefore, unsure of fracture.
Preexisting Conditions: Dementia, PVD, Vit D deficiency, anxiety, HTN, Afib, postrial kyphosis, CHF, UTIs, Debility, sundowning, skin neoplasm left side of nose
Allergies: Fosomax Fosomax
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt received moderna vaccine #2 at 1:30pm. No s/s of adverse reactions. Ate dinner at 4pm. She was in her room at 430pm and she slid out of her chair and was laying on her Right side. She reported she slid out of her chair because she needed to go urinate per staff. She denied pain. At 630p complained of right hip pain. mobile xray was ordered. At 825pm resident was sleeping x 30 mins in her bed when she was found to have no pulse or respirations. She ceased to breathe. Mobile xray did not make it on time.


Changed on 5/14/2021

VAERS ID: 1041719 Before After
VAERS Form:2
Age:92.0
Sex:Female
Location:West Virginia
Vaccinated:2021-02-17
Onset:2021-02-17
Submitted:0000-00-00
Entered:2021-02-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030M20A / 2 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Arthralgia, Death, Fall, Pulse absent, Respiratory arrest

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-17
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: Depakote, lasix, memantine, metoprolol, senna s, vit D3, miralax, xarelto, remeron
Current Illness: Resident slid out of recliner at 430pm on the date of vaccine and death. Denied pain and ROM was without issues. At 630pm she complained of right hip pain. Mobile xray was ordered. Resident passed in her bed after sleeping for 30 mins. Xray did not make it on time, therefore, unsure of fracture.
Preexisting Conditions: Dementia, PVD, Vit D deficiency, anxiety, HTN, Afib, postrial kyphosis, CHF, UTIs, Debility, sundowning, skin neoplasm left side of nose
Allergies: Fosomax Fosomax
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Pt received moderna vaccine #2 at 1:30pm. No s/s of adverse reactions. Ate dinner at 4pm. She was in her room at 430pm and she slid out of her chair and was laying on her Right side. She reported she slid out of her chair because she needed to go urinate per staff. She denied pain. At 630p complained of right hip pain. mobile xray was ordered. At 825pm resident was sleeping x 30 mins in her bed when she was found to have no pulse or respirations. She ceased to breathe. Mobile xray did not make it on time.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1041719&WAYBACKHISTORY=ON

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