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This is VAERS ID 1084793

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History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1084793
VAERS Form:2
Age:60.0
Sex:Female
Location:Massachusetts
Vaccinated:2021-03-05
Onset:2021-03-06
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, Hypoglycaemia, Hypotension, Sepsis, Gastrostomy, Fluid replacement

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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


Changed on 5/7/2021

VAERS ID: 1084793 Before After
VAERS Form:2
Age:60.0
Sex:Female
Location:Massachusetts
Vaccinated:2021-03-05
Onset:2021-03-06
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, Hypoglycaemia, Hypotension, Sepsis, Gastrostomy, Fluid replacement

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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 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


Changed on 5/14/2021

VAERS ID: 1084793 Before After
VAERS Form:2
Age:60.0
Sex:Female
Location:Massachusetts
Vaccinated:2021-03-05
Onset:2021-03-06
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, Hypoglycaemia, Hypotension, Sepsis, Gastrostomy, Fluid replacement

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-06
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? 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 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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