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This is VAERS ID 1274675

History of Changes from the VAERS Wayback Machine

First Appeared on 5/7/2021

VAERS ID: 1274675
VAERS Form:2
Age:67.0
Sex:Female
Location:Texas
Vaccinated:2021-04-23
Onset:2021-04-23
Submitted:0000-00-00
Entered:2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046A21A / 2 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood glucose decreased, Cardiac arrest, Death, Moaning, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-23
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: Humalog Lactulose 20 gram/30 mL solution Lumigan (bimatoprost) 0.01% drops Midodrine 10 mg tablet Rena-Vite Renvela 800 mg Sertraline 50 mg tablet
Current Illness:
Preexisting Conditions: Type 2 Diabetes, Hypertension, Hyperlipidemia, ESRD, Anemia, Hypothyroidism, Coronary Artery Disease, Cardiomyopathy, Liver Cirrhosis, GERD, Anxiety, Depression
Allergies: No know drug allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Vaccine was administered at 1215, patient was monitored for 15minutes per CDC guidelines with not adverse reactions noted. Approximately one hour after administration of vaccine patient noted to be moaning, fingerstick BS at 59mg/dL, Dextrose administered, pt proceeded in to cardiac arrest, CPR was initiated and EMS activated. Pt expired approximately 4 hours after incident at ER.


Changed on 5/14/2021

VAERS ID: 1274675 Before After
VAERS Form:2
Age:67.0
Sex:Female
Location:Texas
Vaccinated:2021-04-23
Onset:2021-04-23
Submitted:0000-00-00
Entered:2021-04-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 046A21A / 2 LA / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood glucose decreased, Cardiac arrest, Death, Moaning, Resuscitation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-23
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: Humalog Lactulose 20 gram/30 mL solution Lumigan (bimatoprost) 0.01% drops Midodrine 10 mg tablet Rena-Vite Renvela 800 mg Sertraline 50 mg tablet
Current Illness:
Preexisting Conditions: Type 2 Diabetes, Hypertension, Hyperlipidemia, ESRD, Anemia, Hypothyroidism, Coronary Artery Disease, Cardiomyopathy, Liver Cirrhosis, GERD, Anxiety, Depression
Allergies: No know drug allergies allergies
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Vaccine was administered at 1215, patient was monitored for 15minutes per CDC guidelines with not adverse reactions noted. Approximately one hour after administration of vaccine patient noted to be moaning, fingerstick BS at 59mg/dL, Dextrose administered, pt proceeded in to cardiac arrest, CPR was initiated and EMS activated. Pt expired approximately 4 hours after incident at ER.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1274675&WAYBACKHISTORY=ON

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