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This is VAERS ID 1249559

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1249559
VAERS Form:2
Age:
Sex:Female
Location:New Jersey
Vaccinated:0000-00-00
Onset:2021-04-08
Submitted:0000-00-00
Entered:2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Cardiac arrest, Pulmonary embolism, Respiratory distress

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-11
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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Lipid metabolism disorder NOS
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: respiratory distress; cardiac arrest; pulmonary emboliasm; This spontaneous case was reported by a consumer and describes the occurrence of RESPIRATORY DISTRESS (respiratory distress), CARDIAC ARREST (cardiac arrest) and PULMONARY EMBOLISM (pulmonary emboliasm) in a 76-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Lipid metabolism disorder NOS. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 08-Apr-2021, the patient experienced RESPIRATORY DISTRESS (respiratory distress) (seriousness criterion death), CARDIAC ARREST (cardiac arrest) (seriousness criterion death) and PULMONARY EMBOLISM (pulmonary emboliasm) (seriousness criterion death). The patient died on 11-Apr-2021. It is unknown if an autopsy was performed. Not Provided For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. NO treatment or Concomitant medication were provided. Company Comment This is a case of sudden death in a 76-year-old female patient with a history of Lipid metabolism disorder, who died (date unknown) of respiratory distress, cardiac arrest and PULMONARY EMBOLISM after receiving first dose of vaccine. Very limited information has been provided at this time.


Changed on 5/7/2021

VAERS ID: 1249559 Before After
VAERS Form:2
Age:
Sex:Female
Location:New Jersey
Vaccinated:0000-00-00
Onset:2021-04-08
Submitted:0000-00-00
Entered:2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Cardiac arrest, Pulmonary embolism, Respiratory distress

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-11
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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Lipid metabolism disorder NOS
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: respiratory distress; cardiac arrest; pulmonary emboliasm; This spontaneous case was reported by a consumer and describes the occurrence of RESPIRATORY DISTRESS (respiratory distress), CARDIAC ARREST (cardiac arrest) and PULMONARY EMBOLISM (pulmonary emboliasm) in a 76-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Lipid metabolism disorder NOS. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 08-Apr-2021, the patient experienced RESPIRATORY DISTRESS (respiratory distress) (seriousness criterion death), CARDIAC ARREST (cardiac arrest) (seriousness criterion death) and PULMONARY EMBOLISM (pulmonary emboliasm) (seriousness criterion death). The patient died on 11-Apr-2021. It is unknown if an autopsy was performed. Not Provided For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. NO treatment or Concomitant medication were provided. Company Comment This is a case of sudden death in a 76-year-old female patient with a history of Lipid metabolism disorder, who died (date unknown) of respiratory distress, cardiac arrest and PULMONARY EMBOLISM after receiving first dose of vaccine. Very limited information has been provided at this time.


Changed on 5/21/2021

VAERS ID: 1249559 Before After
VAERS Form:2
Age:
Sex:Female
Location:New Jersey
Vaccinated:0000-00-00
Onset:2021-04-08
Submitted:0000-00-00
Entered:2021-04-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 - / OT

Administered by: Unknown      Purchased by: ??
Symptoms: Cardiac arrest, Pulmonary embolism, Respiratory distress

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-11
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:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Lipid metabolism disorder NOS
Allergies:
Diagnostic Lab Data:
CDC 'Split Type': USMODERNATX, INC.MOD20210

Write-up: respiratory distress; cardiac arrest; pulmonary emboliasm; This spontaneous case was reported by a consumer and describes the occurrence of RESPIRATORY DISTRESS (respiratory distress), CARDIAC ARREST (cardiac arrest) and PULMONARY EMBOLISM (pulmonary emboliasm) in a 76-year-old female patient who received mRNA-1273 (Moderna COVID-19 Vaccine) for COVID-19 vaccination. Concurrent medical conditions included Lipid metabolism disorder NOS. On an unknown date, the patient received first dose of mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular) 1 dosage form. On 08-Apr-2021, the patient experienced RESPIRATORY DISTRESS (respiratory distress) (seriousness criterion death), CARDIAC ARREST (cardiac arrest) (seriousness criterion death) and PULMONARY EMBOLISM (pulmonary emboliasm) (seriousness criterion death). The patient died on 11-Apr-2021. It is unknown if an autopsy was performed. Not Provided For mRNA-1273 (Moderna COVID-19 Vaccine) (Intramuscular), the reporter did not provide any causality assessments. NO treatment or Concomitant medication were provided. Company Comment This is a case of sudden death in a 76-year-old female patient with a history of Lipid metabolism disorder, who died (date unknown) of respiratory distress, cardiac arrest and PULMONARY EMBOLISM after receiving first dose of vaccine. Very limited information has been provided at this time.

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