National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1053978

History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1053978
VAERS Form:2
Age:77.0
Sex:Female
Location:Georgia
Vaccinated:2021-02-23
Onset:2021-02-24
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Chills, Death, Pain, Pyrexia, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-24
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: Albuterol sulfate inhaler, atenolol, ipatropium-albuterol nebulizer, Sensipar, lisinopril, Incruse Ellipta, lovastatin, pantoprazole, furosemide, trazodone, diclofenac gel, triamcinolone cream, fluticasone nasal spray
Current Illness: none
Preexisting Conditions: CKD Stage 3, COPD, hyperlipidemia, secondary hyperparathyroidism
Allergies: NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt woke up at 0400 with fever, chills, and body aches progressing over 4 hours to the point when she became unresponsive. husband called 911, pt was declared dead at the time of EMS arrival around 1200


Changed on 5/7/2021

VAERS ID: 1053978 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:Georgia
Vaccinated:2021-02-23
Onset:2021-02-24
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Chills, Death, Pain, Pyrexia, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-24
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: Albuterol sulfate inhaler, atenolol, ipatropium-albuterol nebulizer, Sensipar, lisinopril, Incruse Ellipta, lovastatin, pantoprazole, furosemide, trazodone, diclofenac gel, triamcinolone cream, fluticasone nasal spray
Current Illness: none
Preexisting Conditions: CKD Stage 3, COPD, hyperlipidemia, secondary hyperparathyroidism
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt woke up at 0400 with fever, chills, and body aches progressing over 4 hours to the point when she became unresponsive. husband called 911, pt was declared dead at the time of EMS arrival around 1200


Changed on 5/14/2021

VAERS ID: 1053978 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:Georgia
Vaccinated:2021-02-23
Onset:2021-02-24
Submitted:0000-00-00
Entered:2021-02-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 015M20A / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Chills, Death, Pain, Pyrexia, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-24
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: Albuterol sulfate inhaler, atenolol, ipatropium-albuterol nebulizer, Sensipar, lisinopril, Incruse Ellipta, lovastatin, pantoprazole, furosemide, trazodone, diclofenac gel, triamcinolone cream, fluticasone nasal spray
Current Illness: none
Preexisting Conditions: CKD Stage 3, COPD, hyperlipidemia, secondary hyperparathyroidism
Allergies: NKDA NKDA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: pt woke up at 0400 with fever, chills, and body aches progressing over 4 hours to the point when she became unresponsive. husband called 911, pt was declared dead at the time of EMS arrival around 1200

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1053978&WAYBACKHISTORY=ON

Government Disclaimer on use of this data


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166