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This is VAERS ID 1049997

History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1049997
VAERS Form:2
Age:89.0
Sex:Female
Location:South Carolina
Vaccinated:2021-01-08
Onset:2021-01-08
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / SYR

Administered by: Other      Purchased by: ??
Symptoms: Aphasia, Death, Hypotension, Tachypnoea

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
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: Pliavis, tramadol, aspirin, statin, remeron, protonix
Current Illness: none identified
Preexisting Conditions: Heart Rhythm Irregularity, High Cholesterol, Arthritis, Hypertension, CVA/TIA/Stroke, GERD/Reflux, Sleep Apnea, Heart Disease
Allergies: Ace inhibitors, solifenacin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Vaccine was administered at Nursing Facility. Patient is an 89-year-old female with prior medical history of CVA with dysphagia, history of possible dementia, GERD, hyperlipidemia, and a pacemaker. She is a resident from town. She was sent for hypotension with a blood pressure of 90/52, tachypnea respirations of 54, possible aspiration pneumonia. Status post Covid vaccine earlier today. History is limited as patient is nonverbal on my exam. Death within 24 hours of vaccination


Changed on 5/7/2021

VAERS ID: 1049997 Before After
VAERS Form:2
Age:89.0
Sex:Female
Location:South Carolina
Vaccinated:2021-01-08
Onset:2021-01-08
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / SYR

Administered by: Other      Purchased by: ??
Symptoms: Aphasia, Death, Hypotension, Tachypnoea

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
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: Pliavis, tramadol, aspirin, statin, remeron, protonix
Current Illness: none identified
Preexisting Conditions: Heart Rhythm Irregularity, High Cholesterol, Arthritis, Hypertension, CVA/TIA/Stroke, GERD/Reflux, Sleep Apnea, Heart Disease
Allergies: Ace inhibitors, solifenacin solifenacin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Vaccine was administered at Nursing Facility. Patient is an 89-year-old female with prior medical history of CVA with dysphagia, history of possible dementia, GERD, hyperlipidemia, and a pacemaker. She is a resident from town. She was sent for hypotension with a blood pressure of 90/52, tachypnea respirations of 54, possible aspiration pneumonia. Status post Covid vaccine earlier today. History is limited as patient is nonverbal on my exam. Death within 24 hours of vaccination


Changed on 5/14/2021

VAERS ID: 1049997 Before After
VAERS Form:2
Age:89.0
Sex:Female
Location:South Carolina
Vaccinated:2021-01-08
Onset:2021-01-08
Submitted:0000-00-00
Entered:2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK UN / SYR

Administered by: Other      Purchased by: ??
Symptoms: Aphasia, Death, Hypotension, Tachypnoea

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-08
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: Pliavis, tramadol, aspirin, statin, remeron, protonix
Current Illness: none identified
Preexisting Conditions: Heart Rhythm Irregularity, High Cholesterol, Arthritis, Hypertension, CVA/TIA/Stroke, GERD/Reflux, Sleep Apnea, Heart Disease
Allergies: Ace inhibitors, solifenacin solifenacin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Vaccine was administered at Nursing Facility. Patient is an 89-year-old female with prior medical history of CVA with dysphagia, history of possible dementia, GERD, hyperlipidemia, and a pacemaker. She is a resident from town. She was sent for hypotension with a blood pressure of 90/52, tachypnea respirations of 54, possible aspiration pneumonia. Status post Covid vaccine earlier today. History is limited as patient is nonverbal on my exam. Death within 24 hours of vaccination

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