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This is VAERS ID 1273511

History of Changes from the VAERS Wayback Machine

First Appeared on 5/7/2021

VAERS ID: 1273511
VAERS Form:2
Age:84.0
Sex:Female
Location:Tennessee
Vaccinated:2021-03-25
Onset:2021-04-17
Submitted:0000-00-00
Entered:2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / 2 - / -

Administered by: Public      Purchased by: ??
Symptoms: Atrial fibrillation, Chest X-ray abnormal, Death, Lung consolidation, Nausea, Septic shock, Unresponsive to stimuli, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-18
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: Warfarin, Alendronate, Omeprazole, Rosuvastatin, Losartan, Metoprolol, Hydrochlorithiazide
Current Illness: None
Preexisting Conditions: DM II, CKD, Osteoporosis, Hypertensive heart and kidney diease, Hyperlipid, B12 deficiency, History of DVT
Allergies: Side effects to Actonel and Atorvastatin
Diagnostic Lab Data: CXR- mild bilateral bibasilar airspace disease
CDC 'Split Type':

Write-up: Patient recieved Moderna dose 1 02/23/2021, dose 2 03/25/2021. Nausea and vomitting after 2nd dose, found unresponsive by son on 04/17/2021, taken to ER and diagnosed with new onset Afib with RVR, sepsis with shock. Deceased 04/18/2021


Changed on 5/14/2021

VAERS ID: 1273511 Before After
VAERS Form:2
Age:84.0
Sex:Female
Location:Tennessee
Vaccinated:2021-03-25
Onset:2021-04-17
Submitted:0000-00-00
Entered:2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 017B21A / 2 - / -

Administered by: Public      Purchased by: ??
Symptoms: Atrial fibrillation, Chest X-ray abnormal, Death, Lung consolidation, Nausea, Septic shock, Unresponsive to stimuli, Vomiting

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-18
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: Warfarin, Alendronate, Omeprazole, Rosuvastatin, Losartan, Metoprolol, Hydrochlorithiazide
Current Illness: None
Preexisting Conditions: DM II, CKD, Osteoporosis, Hypertensive heart and kidney diease, Hyperlipid, B12 deficiency, History of DVT
Allergies: Side effects to Actonel and Atorvastatin Atorvastatin
Diagnostic Lab Data: CXR- mild bilateral bibasilar airspace disease
CDC 'Split Type':

Write-up: Patient recieved Moderna dose 1 02/23/2021, dose 2 03/25/2021. Nausea and vomitting after 2nd dose, found unresponsive by son on 04/17/2021, taken to ER and diagnosed with new onset Afib with RVR, sepsis with shock. Deceased 04/18/2021

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1273511&WAYBACKHISTORY=ON

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