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From the 10/8/2021 release of VAERS data:

This is VAERS ID 1084793



Case Details

VAERS ID: 1084793 (history)  
Form: Version 2.0  
Age: 60.0  
Sex: Female  
Location: Massachusetts  
Vaccinated:2021-03-05
Onset:2021-03-06
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011A21A / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Acute abdomen, Cardiogenic shock, Death, Fluid replacement, Gastrostomy, Hypoglycaemia, Hypotension, Sepsis
SMQs:, Cardiac failure (narrow), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Hypoglycaemia (narrow), Dehydration (narrow), Hypokalaemia (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-06
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol 650mg q6h prn, Eliquis 5mg BID, Albuterol MDI q6h prn, Atenolol 75mg daily , Atorvastatin 80mg daily , Questran 4gm daily, Lexapro 25mg daily, ferrous sulfate 300mg daily, fluconazole 400mg daily, Lasix 10mg daily, Lispro in
Current Illness: angioedema thought to be secondary to lisinopril esophageal perforation abdominal ascites
Preexisting Conditions: AFIB HTN GERD depression
Allergies: Lisinopril Naproxen Gadolinium
Diagnostic Lab Data:
CDC Split Type:

Write-up: Hypotension in the 70s/40s despite IV fluid replenishment. Per our MD DC/transfer note: PEG displacement, ongoing sepsis, hypoglycemia. Assess for other reason for hypotension including sepsis, cardiogenic shock, acute abdominal processes. patient was transferred to the Hospital ER where she expired


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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1084793

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