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This is VAERS ID 1056972

History of Changes from the VAERS Wayback Machine

First Appeared on 3/5/2021

VAERS ID: 1056972
VAERS Form:2
Age:77.0
Sex:Female
Location:Maine
Vaccinated:2021-01-29
Onset:2021-02-04
Submitted:0000-00-00
Entered:2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Abdominal pain, Acute myocardial infarction, Antiphospholipid syndrome, Atrial fibrillation, Cerebrovascular accident, Diarrhoea, Dysphagia, Electrocardiogram QT prolonged, Encephalopathy, Endoscopy, Hepatic cirrhosis, Leukocytosis, Malaise, Oesophageal varices haemorrhage, Supraventricular tachycardia, Thrombosis, Biliary dilatation, Gastrointestinal oedema, Intestinal mass, Laboratory test, Peritonitis bacterial, Imaging procedure, Intestinal angioedema, Intracranial mass

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen
Current Illness:
Preexisting Conditions: Depression Hyperlipidemia Anxiety disorder Elevated BP without diagnosis of hypertension Alcohol abuse Osteopenia Tubular adenoma of colon Serrated adenoma of colon Cyst of left breast
Allergies: Ampicillin-nausea
Diagnostic Lab Data: Pt. has had multiple lab tests, imaging studies, endoscopic procedures. Too numerous to list here. Current Hospital diagnoses as of 02/26/2021 Hospital SVT (supraventricular tachycardia) (CMS-HCC) Thrombus Acute encephalopathy Dysphagia, unspecified Non-ST elevation (NSTEMI) myocardial infarction (CMS-HCC) Prolonged Q-T interval on ECG Leukocytosis A-fib (CMS-HCC) Common bile duct dilation Duodenal mass Cirrhosis (CMS-HCC) Small bowel edema Stroke (CMS-HCC) Bleeding esophageal varices (CMS-HCC) SBP (spontaneous bacterial peritonitis) (CMS-HCC) Catastrophic antiphospholipid syndrome (CMS-HCC)
CDC 'Split Type':

Write-up: 5-6 days after receiving first Moderna covid vaccine pt. began not feeling well. On 02/10/2021 she saw a provider in an office for eval of abdominal pain and diarrhea and sent home. On 02/15/2021 she presented to a local ED with continuing symptoms, transferred to Medical Center, She is currently an inpatient there with a diagnosis of multiple blood clots in abdomen and brain and antiphospholipid syndrome.


Changed on 5/7/2021

VAERS ID: 1056972 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:Maine
Vaccinated:2021-01-29
Onset:2021-02-04
Submitted:0000-00-00
Entered:2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Abdominal pain, Acute myocardial infarction, Antiphospholipid syndrome, Atrial fibrillation, Cerebrovascular accident, Diarrhoea, Dysphagia, Electrocardiogram QT prolonged, Encephalopathy, Endoscopy, Hepatic cirrhosis, Leukocytosis, Malaise, Oesophageal varices haemorrhage, Supraventricular tachycardia, Thrombosis, Biliary dilatation, Gastrointestinal oedema, Intestinal mass, Laboratory test, Peritonitis bacterial, Imaging procedure, Intestinal angioedema, Intracranial mass

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen
Current Illness:
Preexisting Conditions: Depression Hyperlipidemia Anxiety disorder Elevated BP without diagnosis of hypertension Alcohol abuse Osteopenia Tubular adenoma of colon Serrated adenoma of colon Cyst of left breast
Allergies: Ampicillin-nausea Ampicillin-nausea
Diagnostic Lab Data: Pt. has had multiple lab tests, imaging studies, endoscopic procedures. Too numerous to list here. Current Hospital diagnoses as of 02/26/2021 Hospital SVT (supraventricular tachycardia) (CMS-HCC) Thrombus Acute encephalopathy Dysphagia, unspecified Non-ST elevation (NSTEMI) myocardial infarction (CMS-HCC) Prolonged Q-T interval on ECG Leukocytosis A-fib (CMS-HCC) Common bile duct dilation Duodenal mass Cirrhosis (CMS-HCC) Small bowel edema Stroke (CMS-HCC) Bleeding esophageal varices (CMS-HCC) SBP (spontaneous bacterial peritonitis) (CMS-HCC) Catastrophic antiphospholipid syndrome (CMS-HCC)
CDC 'Split Type':

Write-up: 5-6 days after receiving first Moderna covid vaccine pt. began not feeling well. On 02/10/2021 she saw a provider in an office for eval of abdominal pain and diarrhea and sent home. On 02/15/2021 she presented to a local ED with continuing symptoms, transferred to Medical Center, She is currently an inpatient there with a diagnosis of multiple blood clots in abdomen and brain and antiphospholipid syndrome.


Changed on 5/14/2021

VAERS ID: 1056972 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:Maine
Vaccinated:2021-01-29
Onset:2021-02-04
Submitted:0000-00-00
Entered:2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Abdominal pain, Acute myocardial infarction, Antiphospholipid syndrome, Atrial fibrillation, Cerebrovascular accident, Diarrhoea, Dysphagia, Electrocardiogram QT prolonged, Encephalopathy, Endoscopy, Hepatic cirrhosis, Leukocytosis, Malaise, Oesophageal varices haemorrhage, Supraventricular tachycardia, Thrombosis, Biliary dilatation, Gastrointestinal oedema, Intestinal mass, Laboratory test, Peritonitis bacterial, Imaging procedure, Intestinal angioedema, Intracranial mass

Life Threatening? Yes
Birth Defect? No
Died? No
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen
Current Illness:
Preexisting Conditions: Depression Hyperlipidemia Anxiety disorder Elevated BP without diagnosis of hypertension Alcohol abuse Osteopenia Tubular adenoma of colon Serrated adenoma of colon Cyst of left breast
Allergies: Ampicillin-nausea Ampicillin-nausea
Diagnostic Lab Data: Pt. has had multiple lab tests, imaging studies, endoscopic procedures. Too numerous to list here. Current Hospital diagnoses as of 02/26/2021 Hospital SVT (supraventricular tachycardia) (CMS-HCC) Thrombus Acute encephalopathy Dysphagia, unspecified Non-ST elevation (NSTEMI) myocardial infarction (CMS-HCC) Prolonged Q-T interval on ECG Leukocytosis A-fib (CMS-HCC) Common bile duct dilation Duodenal mass Cirrhosis (CMS-HCC) Small bowel edema Stroke (CMS-HCC) Bleeding esophageal varices (CMS-HCC) SBP (spontaneous bacterial peritonitis) (CMS-HCC) Catastrophic antiphospholipid syndrome (CMS-HCC)
CDC 'Split Type':

Write-up: 5-6 days after receiving first Moderna covid vaccine pt. began not feeling well. On 02/10/2021 she saw a provider in an office for eval of abdominal pain and diarrhea and sent home. On 02/15/2021 she presented to a local ED with continuing symptoms, transferred to Medical Center, She is currently an inpatient there with a diagnosis of multiple blood clots in abdomen and brain and antiphospholipid syndrome.


Changed on 6/25/2021

VAERS ID: 1056972 Before After
VAERS Form:2
Age:77.0
Sex:Female
Location:Maine
Vaccinated:2021-01-29
Onset:2021-02-04
Submitted:0000-00-00
Entered:2021-02-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Abdominal pain, Acute myocardial infarction, Antiphospholipid syndrome, Atrial fibrillation, Cerebrovascular accident, Diarrhoea, Dysphagia, Electrocardiogram QT prolonged, Encephalopathy, Endoscopy, Hepatic cirrhosis, Leukocytosis, Malaise, Oesophageal varices haemorrhage, Supraventricular tachycardia, Thrombosis, Biliary dilatation, Gastrointestinal oedema, Intestinal mass, Laboratory test, Peritonitis bacterial, Imaging procedure, Intestinal angioedema, Intracranial mass

Life Threatening? Yes
Birth Defect? No
Died? No Yes
   Date died:0000-00-00 2021-02-27
Permanent Disability? Yes
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen
Current Illness:
Preexisting Conditions: Depression Hyperlipidemia Anxiety disorder Elevated BP without diagnosis of hypertension Alcohol abuse Osteopenia Tubular adenoma of colon Serrated adenoma of colon Cyst of left breast
Allergies: Ampicillin-nausea
Diagnostic Lab Data: Pt. has had multiple lab tests, imaging studies, endoscopic procedures. Too numerous to list here. Current Hospital diagnoses as of 02/26/2021 Hospital SVT (supraventricular tachycardia) (CMS-HCC) Thrombus Acute encephalopathy Dysphagia, unspecified Non-ST elevation (NSTEMI) myocardial infarction (CMS-HCC) Prolonged Q-T interval on ECG Leukocytosis A-fib (CMS-HCC) Common bile duct dilation Duodenal mass Cirrhosis (CMS-HCC) Small bowel edema Stroke (CMS-HCC) Bleeding esophageal varices (CMS-HCC) SBP (spontaneous bacterial peritonitis) (CMS-HCC) Catastrophic antiphospholipid syndrome (CMS-HCC)
CDC 'Split Type':

Write-up: 5-6 days after receiving first Moderna covid vaccine pt. began not feeling well. On 02/10/2021 she saw a provider in an office for eval of abdominal pain and diarrhea and sent home. On 02/15/2021 she presented to a local ED with continuing symptoms, transferred to Medical Center, Center. She is currently an inpatient there with a diagnosis of multiple blood clots in abdomen and brain and antiphospholipid syndrome.

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