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This is VAERS ID 907075

History of Changes from the VAERS Wayback Machine

First Appeared on 12/30/2020

VAERS ID: 907075
VAERS Form:2
Age:43.0
Sex:Female
Location:Ohio
Vaccinated:2020-12-22
Onset:2020-12-22
Submitted:0000-00-00
Entered:2020-12-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Bronchospasm, Cough, Tongue pruritus

Life Threatening? Yes
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)? Yes
Hospitalized? No
Previous Vaccinations: Influenza - other information unknown
Other Medications: Prescription: atenolol, omeprazole, simvastatin, primidone, levothyroxine, escitalopram, albuterol inhaler
Current Illness: no
Preexisting Conditions: Hypothyroidism, asthma, high cholesterol, palpitations, essential tremor, anxiety, depression, hiatal hernia
Allergies: Medication allergies: morphine - anaphylaxis, flexeril - mood and behavior disturbances, zolpidem- shortness of breath, lamotrigine - shortness of breath Patient had a previous reaction to influenza vaccination with shortness of breath
Diagnostic Lab Data: BMP, CBC w/diff, trop/myoglobin x2, TSH, Free T4, Chest X-ray (all ordered 12/22/20)
CDC 'Split Type':

Write-up: Patient experienced bronchospasm with coughing and tongue itching approximately 10 minutes after the injection.


Changed on 5/7/2021

VAERS ID: 907075 Before After
VAERS Form:2
Age:43.0
Sex:Female
Location:Ohio
Vaccinated:2020-12-22
Onset:2020-12-22
Submitted:0000-00-00
Entered:2020-12-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Bronchospasm, Cough, Tongue pruritus

Life Threatening? Yes
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)? Yes
Hospitalized? No
Previous Vaccinations: Influenza - other information unknown
Other Medications: Prescription: atenolol, omeprazole, simvastatin, primidone, levothyroxine, escitalopram, albuterol inhaler
Current Illness: no
Preexisting Conditions: Hypothyroidism, asthma, high cholesterol, palpitations, essential tremor, anxiety, depression, hiatal hernia
Allergies: Medication allergies: morphine - anaphylaxis, flexeril - mood and behavior disturbances, zolpidem- shortness of breath, lamotrigine - shortness of breath Patient had a previous reaction to influenza vaccination with shortness of breath breath
Diagnostic Lab Data: BMP, CBC w/diff, trop/myoglobin x2, TSH, Free T4, Chest X-ray (all ordered 12/22/20)
CDC 'Split Type':

Write-up: Patient experienced bronchospasm with coughing and tongue itching approximately 10 minutes after the injection.


Changed on 5/14/2021

VAERS ID: 907075 Before After
VAERS Form:2
Age:43.0
Sex:Female
Location:Ohio
Vaccinated:2020-12-22
Onset:2020-12-22
Submitted:0000-00-00
Entered:2020-12-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 039K20A / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Bronchospasm, Cough, Tongue pruritus

Life Threatening? Yes
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)? Yes
Hospitalized? No
Previous Vaccinations: Influenza - other information unknown
Other Medications: Prescription: atenolol, omeprazole, simvastatin, primidone, levothyroxine, escitalopram, albuterol inhaler
Current Illness: no
Preexisting Conditions: Hypothyroidism, asthma, high cholesterol, palpitations, essential tremor, anxiety, depression, hiatal hernia
Allergies: Medication allergies: morphine - anaphylaxis, flexeril - mood and behavior disturbances, zolpidem- shortness of breath, lamotrigine - shortness of breath Patient had a previous reaction to influenza vaccination with shortness of breath breath
Diagnostic Lab Data: BMP, CBC w/diff, trop/myoglobin x2, TSH, Free T4, Chest X-ray (all ordered 12/22/20)
CDC 'Split Type':

Write-up: Patient experienced bronchospasm with coughing and tongue itching approximately 10 minutes after the injection.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=907075&WAYBACKHISTORY=ON

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