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This is VAERS ID 911829

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 911829
VAERS Form:2
Age:80.0
Sex:Female
Location:Michigan
Vaccinated:2020-12-28
Onset:2020-12-29
Submitted:0000-00-00
Entered:2020-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Asthenia, Unresponsive to stimuli, Decreased appetite

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)? Yes
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin Tablet 81 MG Give 1 tablet by mouth in the morning Bisoprolol Fumarate Tablet 5 MG Give 1 tablet by mouth in the morning for HTN Flomax Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth in the evening Levothyroxine Sodium Ta
Current Illness: U07.1 COVID-19
Preexisting Conditions: F03.91 UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE R26.9 UNSPECIFIED ABNORMALITIES OF GAIT AND MOBILITY M62.81 MUSCLE WEAKNESS (GENERALIZED) Z74.1 NEED FOR ASSISTANCE WITH PERSONAL CARE N13.9 OBSTRUCTIVE AND REFLUX UROPATHY, UNSPECIFIED N13.2 HYDRONEPHROSIS WITH RENAL AND URETERAL CALCULOUS OBSTRUCTION R45.4 IRRITABILITY AND ANGER F06.34 MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXED FEATURES G93.41 METABOLIC ENCEPHALOPATHY I25.10 ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS F06.2 PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION F06.0 PSYCHOTIC DISORDER WITH HALLUCINATIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION R26.2 DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED I10 ESSENTIAL (PRIMARY) HYPERTENSION K21.9 GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS E11.9 TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS E78.5 HYPERLIPIDEMIA, UNSPECIFIED E03.9 HYPOTHYROIDISM, UNSPECIFIED F41.9 ANXIETY DISORDER, UNSPECIFIED E11.40 TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED E66.01 MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIES J30.9 ALLERGIC RHINITIS, UNSPECIFIED F33.9 MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED F43.23 ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD R48.8 OTHER SYMBOLIC DYSFUNCTIONS
Allergies: Latex
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Resident found unresponsive in her room. Note from earlier: Resident appears to be weak today. Resident ate a few bites of dinner before refusing the tray. Writer encouraged fluids. Vitals 123/72 80HR BS 166. Will log for Doctor and continue to monitor. Was sent out 911.


Changed on 5/7/2021

VAERS ID: 911829 Before After
VAERS Form:2
Age:80.0
Sex:Female
Location:Michigan
Vaccinated:2020-12-28
Onset:2020-12-29
Submitted:0000-00-00
Entered:2020-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Asthenia, Unresponsive to stimuli, Decreased appetite

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)? Yes
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin Tablet 81 MG Give 1 tablet by mouth in the morning Bisoprolol Fumarate Tablet 5 MG Give 1 tablet by mouth in the morning for HTN Flomax Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth in the evening Levothyroxine Sodium Ta
Current Illness: U07.1 COVID-19
Preexisting Conditions: F03.91 UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE R26.9 UNSPECIFIED ABNORMALITIES OF GAIT AND MOBILITY M62.81 MUSCLE WEAKNESS (GENERALIZED) Z74.1 NEED FOR ASSISTANCE WITH PERSONAL CARE N13.9 OBSTRUCTIVE AND REFLUX UROPATHY, UNSPECIFIED N13.2 HYDRONEPHROSIS WITH RENAL AND URETERAL CALCULOUS OBSTRUCTION R45.4 IRRITABILITY AND ANGER F06.34 MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXED FEATURES G93.41 METABOLIC ENCEPHALOPATHY I25.10 ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS F06.2 PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION F06.0 PSYCHOTIC DISORDER WITH HALLUCINATIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION R26.2 DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED I10 ESSENTIAL (PRIMARY) HYPERTENSION K21.9 GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS E11.9 TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS E78.5 HYPERLIPIDEMIA, UNSPECIFIED E03.9 HYPOTHYROIDISM, UNSPECIFIED F41.9 ANXIETY DISORDER, UNSPECIFIED E11.40 TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED E66.01 MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIES J30.9 ALLERGIC RHINITIS, UNSPECIFIED F33.9 MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED F43.23 ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD R48.8 OTHER SYMBOLIC DYSFUNCTIONS
Allergies: Latex Latex
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Resident found unresponsive in her room. Note from earlier: Resident appears to be weak today. Resident ate a few bites of dinner before refusing the tray. Writer encouraged fluids. Vitals 123/72 80HR BS 166. Will log for Doctor and continue to monitor. Was sent out 911.


Changed on 5/14/2021

VAERS ID: 911829 Before After
VAERS Form:2
Age:80.0
Sex:Female
Location:Michigan
Vaccinated:2020-12-28
Onset:2020-12-29
Submitted:0000-00-00
Entered:2020-12-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Asthenia, Unresponsive to stimuli, Decreased appetite

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)? Yes
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Aspirin Tablet 81 MG Give 1 tablet by mouth in the morning Bisoprolol Fumarate Tablet 5 MG Give 1 tablet by mouth in the morning for HTN Flomax Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth in the evening Levothyroxine Sodium Ta
Current Illness: U07.1 COVID-19
Preexisting Conditions: F03.91 UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE R26.9 UNSPECIFIED ABNORMALITIES OF GAIT AND MOBILITY M62.81 MUSCLE WEAKNESS (GENERALIZED) Z74.1 NEED FOR ASSISTANCE WITH PERSONAL CARE N13.9 OBSTRUCTIVE AND REFLUX UROPATHY, UNSPECIFIED N13.2 HYDRONEPHROSIS WITH RENAL AND URETERAL CALCULOUS OBSTRUCTION R45.4 IRRITABILITY AND ANGER F06.34 MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXED FEATURES G93.41 METABOLIC ENCEPHALOPATHY I25.10 ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS F06.2 PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION F06.0 PSYCHOTIC DISORDER WITH HALLUCINATIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION R26.2 DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED I10 ESSENTIAL (PRIMARY) HYPERTENSION K21.9 GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS E11.9 TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS E78.5 HYPERLIPIDEMIA, UNSPECIFIED E03.9 HYPOTHYROIDISM, UNSPECIFIED F41.9 ANXIETY DISORDER, UNSPECIFIED E11.40 TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED E66.01 MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIES J30.9 ALLERGIC RHINITIS, UNSPECIFIED F33.9 MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED F43.23 ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD R48.8 OTHER SYMBOLIC DYSFUNCTIONS
Allergies: Latex Latex
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: Resident found unresponsive in her room. Note from earlier: Resident appears to be weak today. Resident ate a few bites of dinner before refusing the tray. Writer encouraged fluids. Vitals 123/72 80HR BS 166. Will log for Doctor and continue to monitor. Was sent out 911.

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