National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 11/26/2021 release of VAERS data:

This is VAERS ID 1435291

Government Disclaimer on use of this data



Case Details

VAERS ID: 1435291 (history)  
Form: Version 2.0  
Age: 72.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-06-05
Onset:0000-00-00
Submitted: 0000-00-00
Entered: 2021-06-30
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3002917 / UNK - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain upper, Cardiac arrest, Respiratory arrest, Terminal state
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (narrow), Acute pancreatitis (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (narrow), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypersensitivity (broad), Respiratory failure (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-06-07
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Carotid artery atheroma; Cerebral atrophy; Cognitive deterioration; Diabetes mellitus; Hypertensive cardiomyopathy; Hypoxic-ischaemic encephalopathy; Nephropathy; Peripheral obliterative arteriopathy; Retinopathy
Allergies:
Diagnostic Lab Data:
CDC Split Type: ITMODERNATX, INC.MOD20212

Write-up: Concurrent medical conditions included Carotid artery atheroma on 01-Jan-2015, Hypoxic-ischaemic encephalopathy on 11-Oct-2019, Nephropathy, Cerebral atrophy on 11-Oct-2019, Peripheral obliterative arteriopathy on 11-Jun-2021, Cognitive deterioration on 24-Jul-2019, Hypertensive cardiomyopathy on 25-Jun-2018, Diabetes mellitus on 01-Jan-2015 and Retinopathy. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. Concomitant medications were not reported. Treatment information was not provided. This is a case of a 72-year-old female patient with medical history of carotid artery atheroma, hypoxic-ischaemic encephalopathy, nephropathy, cerebral atrophy, peripheral obliterative arteriopathy, cognitive deterioration, hypertensive cardiomyopathy, diabetes mellitus and retinopathy who developed Terminal state, Abdominal pain upper, Cardiac arrest and Respiratory arrest. The patient died due to events and it is unknown if autopsy was performed. Very limited information regarding these events has been provided at this time. No further information is expected. The patient''s advanced age and underlying medical history confound causality.; Sender''s Comments: This is a case of a 72-year-old female patient with medical history of carotid artery atheroma, hypoxic-ischaemic encephalopathy, nephropathy, cerebral atrophy, peripheral obliterative arteriopathy, cognitive deterioration, hypertensive cardiomyopathy, diabetes mellitus and retinopathy who developed Terminal state, Abdominal pain upper, Cardiac arrest and Respiratory arrest. The patient died due to events and it is unknown if autopsy was performed. Very limited information regarding these events has been provided at this time. No further information is expected. The patient''s advanced age and underlying medical history confound causality.; Reported Cause(s) of Death: Arrest cardiac; Epigastralgia; Arrest respiratory


New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1435291


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166