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From the 10/15/2021 release of VAERS data:

This is VAERS ID 1368159



Case Details

VAERS ID: 1368159 (history)  
Form: Version 2.0  
Age: 95.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-03-30
Onset:2021-05-19
   Days after vaccination:50
Submitted: 0000-00-00
Entered: 2021-06-02
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 2 - / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Hypoxia, Oxygen saturation decreased, Renal failure
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (narrow), Asthma/bronchospasm (broad), Retroperitoneal fibrosis (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Tumour lysis syndrome (broad), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-05-31
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 7 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol, Ativan,Hydrocodone.Liquacel,,Morphine Sulfate, Folic Acid, MIralax Powder, Vitamin B-12, Escitalopram, Senna Plus,
Current Illness: Dementia, Absence of left breast, Folate deficiency, GERD, Prediabetes, Glaucoma, Chronic kidney disease stage 3, Pulmonary Nodule, Major Depressive Disorder, Dysphagia, Muscle Weakness, Abnormal weight loss,
Preexisting Conditions: See #11 above
Allergies: Penicillin and Sulfa
Diagnostic Lab Data: She was sent to the emergency room for evaluation and was admitted and diagnosed with kidney failure.
CDC Split Type:

Write-up: Resident became hypoxic and supplemental oxygen did not bring oxygen saturation up to normal levels. The physician ordered resident be sent to the emergency room for evaluation.


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Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1368159

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