National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1103813

History of Changes from the VAERS Wayback Machine

First Appeared on 3/19/2021

VAERS ID: 1103813
VAERS Form:2
Age:67.0
Sex:Female
Location:New York
Vaccinated:2021-02-28
Onset:2021-03-02
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001121A / 1 UN / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Abdominal distension, Chest pain, Death, Dehydration, Dyspnoea, Echocardiogram normal, Electrocardiogram normal, Fatigue, Haemoglobin normal, International normalised ratio normal, Nausea, Pain, Platelet count normal, Prothrombin time normal, Renal failure, Ultrasound kidney normal, Vomiting, White blood cell count normal, Urine analysis normal, Acute kidney injury, Influenza virus test negative, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-13
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Ibrance, vit d, femara, losartan, hctz
Current Illness: HTN, Mild COPD, Breast cancer
Preexisting Conditions: as above
Allergies: None
Diagnostic Lab Data: as above. pt/inr normal, no PE, echo and ekg normal. normal wbc, hgb abd platelets. no new medications to cause renal failure. no imp with ivf. covid neg, flu neg, ua normal. renal us normal.
CDC 'Split Type':

Write-up: Pt was vaccinated on 2/28 and on 3/2 began to experience worsened sob from baseline, development of sternal chest pain, abdominal bloating, nausea and fatigue. She presented to the hospital on 3/9 c/o intractable pain and nausea/vomiting that was worsening. Imaging revealed no change in her cancer from same imaging in jan 2021. PE ruled out. No sepsis. She had acute kidney injury/dehydration. started on ivf. renal imaging normal. echo normal. ekg normal. she rapidly progressed to anuric renal failure and died 3/13/2021. oncology ruled out tumor lysis. she was not felt to be a candidate for dialysis.


Changed on 5/7/2021

VAERS ID: 1103813 Before After
VAERS Form:2
Age:67.0
Sex:Female
Location:New York
Vaccinated:2021-02-28
Onset:2021-03-02
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001121A / 1 UN / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Abdominal distension, Chest pain, Death, Dehydration, Dyspnoea, Echocardiogram normal, Electrocardiogram normal, Fatigue, Haemoglobin normal, International normalised ratio normal, Nausea, Pain, Platelet count normal, Prothrombin time normal, Renal failure, Ultrasound kidney normal, Vomiting, White blood cell count normal, Urine analysis normal, Acute kidney injury, Influenza virus test negative, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-13
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Ibrance, vit d, femara, losartan, hctz
Current Illness: HTN, Mild COPD, Breast cancer
Preexisting Conditions: as above
Allergies: None None
Diagnostic Lab Data: as above. pt/inr normal, no PE, echo and ekg normal. normal wbc, hgb abd platelets. no new medications to cause renal failure. no imp with ivf. covid neg, flu neg, ua normal. renal us normal.
CDC 'Split Type':

Write-up: Pt was vaccinated on 2/28 and on 3/2 began to experience worsened sob from baseline, development of sternal chest pain, abdominal bloating, nausea and fatigue. She presented to the hospital on 3/9 c/o intractable pain and nausea/vomiting that was worsening. Imaging revealed no change in her cancer from same imaging in jan 2021. PE ruled out. No sepsis. She had acute kidney injury/dehydration. started on ivf. renal imaging normal. echo normal. ekg normal. she rapidly progressed to anuric renal failure and died 3/13/2021. oncology ruled out tumor lysis. she was not felt to be a candidate for dialysis.


Changed on 5/14/2021

VAERS ID: 1103813 Before After
VAERS Form:2
Age:67.0
Sex:Female
Location:New York
Vaccinated:2021-02-28
Onset:2021-03-02
Submitted:0000-00-00
Entered:2021-03-16
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 001121A / 1 UN / IM

Administered by: Unknown      Purchased by: ??
Symptoms: Abdominal distension, Chest pain, Death, Dehydration, Dyspnoea, Echocardiogram normal, Electrocardiogram normal, Fatigue, Haemoglobin normal, International normalised ratio normal, Nausea, Pain, Platelet count normal, Prothrombin time normal, Renal failure, Ultrasound kidney normal, Vomiting, White blood cell count normal, Urine analysis normal, Acute kidney injury, Influenza virus test negative, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-13
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? Yes, days: 4     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Ibrance, vit d, femara, losartan, hctz
Current Illness: HTN, Mild COPD, Breast cancer
Preexisting Conditions: as above
Allergies: None None
Diagnostic Lab Data: as above. pt/inr normal, no PE, echo and ekg normal. normal wbc, hgb abd platelets. no new medications to cause renal failure. no imp with ivf. covid neg, flu neg, ua normal. renal us normal.
CDC 'Split Type':

Write-up: Pt was vaccinated on 2/28 and on 3/2 began to experience worsened sob from baseline, development of sternal chest pain, abdominal bloating, nausea and fatigue. She presented to the hospital on 3/9 c/o intractable pain and nausea/vomiting that was worsening. Imaging revealed no change in her cancer from same imaging in jan 2021. PE ruled out. No sepsis. She had acute kidney injury/dehydration. started on ivf. renal imaging normal. echo normal. ekg normal. she rapidly progressed to anuric renal failure and died 3/13/2021. oncology ruled out tumor lysis. she was not felt to be a candidate for dialysis.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1103813&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