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This is VAERS ID 1258236

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History of Changes from the VAERS Wayback Machine

First Appeared on 4/30/2021

VAERS ID: 1258236
VAERS Form:2
Age:93.0
Sex:Female
Location:Mississippi
Vaccinated:2021-04-20
Onset:2021-04-21
Submitted:0000-00-00
Entered:2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030B21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Blood glucose, Chest X-ray abnormal, Death, Depressed level of consciousness, Dysphagia, Full blood count, Hemiparesis, Pneumonia, Unresponsive to stimuli, Urine analysis, Vomiting, Metabolic function test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-22
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: pro stat awc, med pass supplement, Synthroid, neurotin, Metoprolol, Digoxin, Plavix, Cozaar, Mobic, Preservision AREDS, Biotene, Dilantin, Systane balance eye drops, sodium chloride tabs, vitamin D3, lactulose, Tylenol, Norco prn, morphine
Current Illness: Resident had diagonisis of DM type 2, diabetic neropathy, HTN, Hypothyroidism, vit d deficiency, chronic a fib, seizure disorder, metabolic encephalopathy, hyponatremia, macular degeneration, dry mouth, sepsis, hx of PNA, and hx of UTI. The day after vaccine she was diagnosed with PNA.
Preexisting Conditions: Resident was on Hospice. See diagnosis above. The day before she expired she was diagnosed with PNA.
Allergies: Keflex and Penicillin
Diagnostic Lab Data: Resident had a cbc, bmp, chest xray, u/a, and CBG on 4/21/21
CDC 'Split Type':

Write-up: resident was hospice she was afebrile day of vaccine on 4/20. on am of 4/21/21 0600 nurse stated no c/o of pain or discomfort. Resp were even and unlabored. That morning at 1145 charge nurse stated she was extremely hard to rouse. Vs were ok. SHe had some weakness in right side. they notified hospice. She had labs done. She was diagnosed with PNA and started on Abt. That night she was unresponsive to verbal commands and couldn''t get po med. she received gentamicin im. on 4/22/21 charted she was vommiting small amount. She expired late that night. MD doesn''t believe the vaccine caused the death, but thinks it has the potential.


Changed on 5/7/2021

VAERS ID: 1258236 Before After
VAERS Form:2
Age:93.0
Sex:Female
Location:Mississippi
Vaccinated:2021-04-20
Onset:2021-04-21
Submitted:0000-00-00
Entered:2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030B21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Blood glucose, Chest X-ray abnormal, Death, Depressed level of consciousness, Dysphagia, Full blood count, Hemiparesis, Pneumonia, Unresponsive to stimuli, Urine analysis, Vomiting, Metabolic function test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-22
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: pro stat awc, med pass supplement, Synthroid, neurotin, Metoprolol, Digoxin, Plavix, Cozaar, Mobic, Preservision AREDS, Biotene, Dilantin, Systane balance eye drops, sodium chloride tabs, vitamin D3, lactulose, Tylenol, Norco prn, morphine
Current Illness: Resident had diagonisis of DM type 2, diabetic neropathy, HTN, Hypothyroidism, vit d deficiency, chronic a fib, seizure disorder, metabolic encephalopathy, hyponatremia, macular degeneration, dry mouth, sepsis, hx of PNA, and hx of UTI. The day after vaccine she was diagnosed with PNA.
Preexisting Conditions: Resident was on Hospice. See diagnosis above. The day before she expired she was diagnosed with PNA.
Allergies: Keflex and Penicillin Penicillin
Diagnostic Lab Data: Resident had a cbc, bmp, chest xray, u/a, and CBG on 4/21/21
CDC 'Split Type':

Write-up: resident was hospice she was afebrile day of vaccine on 4/20. on am of 4/21/21 0600 nurse stated no c/o of pain or discomfort. Resp were even and unlabored. That morning at 1145 charge nurse stated she was extremely hard to rouse. Vs were ok. SHe had some weakness in right side. they notified hospice. She had labs done. She was diagnosed with PNA and started on Abt. That night she was unresponsive to verbal commands and couldn''t get po med. she received gentamicin im. on 4/22/21 charted she was vommiting small amount. She expired late that night. MD doesn''t believe the vaccine caused the death, but thinks it has the potential.


Changed on 5/14/2021

VAERS ID: 1258236 Before After
VAERS Form:2
Age:93.0
Sex:Female
Location:Mississippi
Vaccinated:2021-04-20
Onset:2021-04-21
Submitted:0000-00-00
Entered:2021-04-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030B21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Blood glucose, Chest X-ray abnormal, Death, Depressed level of consciousness, Dysphagia, Full blood count, Hemiparesis, Pneumonia, Unresponsive to stimuli, Urine analysis, Vomiting, Metabolic function test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-22
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: pro stat awc, med pass supplement, Synthroid, neurotin, Metoprolol, Digoxin, Plavix, Cozaar, Mobic, Preservision AREDS, Biotene, Dilantin, Systane balance eye drops, sodium chloride tabs, vitamin D3, lactulose, Tylenol, Norco prn, morphine
Current Illness: Resident had diagonisis of DM type 2, diabetic neropathy, HTN, Hypothyroidism, vit d deficiency, chronic a fib, seizure disorder, metabolic encephalopathy, hyponatremia, macular degeneration, dry mouth, sepsis, hx of PNA, and hx of UTI. The day after vaccine she was diagnosed with PNA.
Preexisting Conditions: Resident was on Hospice. See diagnosis above. The day before she expired she was diagnosed with PNA.
Allergies: Keflex and Penicillin Penicillin
Diagnostic Lab Data: Resident had a cbc, bmp, chest xray, u/a, and CBG on 4/21/21
CDC 'Split Type':

Write-up: resident was hospice she was afebrile day of vaccine on 4/20. on am of 4/21/21 0600 nurse stated no c/o of pain or discomfort. Resp were even and unlabored. That morning at 1145 charge nurse stated she was extremely hard to rouse. Vs were ok. SHe had some weakness in right side. they notified hospice. She had labs done. She was diagnosed with PNA and started on Abt. That night she was unresponsive to verbal commands and couldn''t get po med. she received gentamicin im. on 4/22/21 charted she was vommiting small amount. She expired late that night. MD doesn''t believe the vaccine caused the death, but thinks it has the potential.

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