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This is VAERS ID 1779331

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/15/2021

VAERS ID: 1779331
VAERS Form:2
Age:57.0
Sex:Female
Location:Illinois
Vaccinated:2021-09-03
Onset:2021-10-05
Submitted:0000-00-00
Entered:2021-10-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 048F21A / 1 - / -

Administered by: Private      Purchased by: ??
Symptoms: Cough, Pyrexia, Respiratory tract congestion

Life Threatening? No
Birth Defect? No
Died? No
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Patient with a history of hypertension, diabetes, GERD, and hyperlipidemia. (Patient''s second dose of Moderna COVID-19 vaccine was given on 10/2/2021, Lot #061E21A. Both doses given at store/pharmacy
Allergies: Aspirin, Diazoxide, Hydrochlorothiazide, Sulfa drugs, Triamterene
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient presents to the ER for evaluation of fever and reports that the second dose of the vaccine was given 3 days prior to admission. Patient endorses cough and congestion since that time. Patient reports onset of fever the day of prior to admission.

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