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This is VAERS ID 919376

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 919376
VAERS Form:2
Age:19.0
Sex:Female
Location:Montana
Vaccinated:2020-12-30
Onset:2021-01-02
Submitted:0000-00-00
Entered:2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Pain of skin, Skin warm, Thrombosis, Limb discomfort, Ultrasound scan abnormal, Limb mass

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Dasetta 1/35, Bile salts OTC, Proair Inhaler PRN
Current Illness: N/a
Preexisting Conditions: Asthma
Allergies: Penicillin
Diagnostic Lab Data: 1/4/2021 confirmed with ultrasound of lower extremity.
CDC 'Split Type':

Write-up: Patient received Moderna vaccine, Wednesday 12/30. On Saturday 1/3/2021 patient felt pressure/tightness in lower extremity. When patient touched area, a noticeable ball was felt under the skin, tender to the touch and warm. Patient went into urgent care on Monday 1/4/2021 with a confirmed dx of a superficial blood clot. Unknown etiology of whether this is from current birth control or the COVID19 Moderna vaccine.


Changed on 5/7/2021

VAERS ID: 919376 Before After
VAERS Form:2
Age:19.0
Sex:Female
Location:Montana
Vaccinated:2020-12-30
Onset:2021-01-02
Submitted:0000-00-00
Entered:2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Pain of skin, Skin warm, Thrombosis, Limb discomfort, Ultrasound scan abnormal, Limb mass

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Dasetta 1/35, Bile salts OTC, Proair Inhaler PRN
Current Illness: N/a
Preexisting Conditions: Asthma
Allergies: Penicillin Penicillin
Diagnostic Lab Data: 1/4/2021 confirmed with ultrasound of lower extremity.
CDC 'Split Type':

Write-up: Patient received Moderna vaccine, Wednesday 12/30. On Saturday 1/3/2021 patient felt pressure/tightness in lower extremity. When patient touched area, a noticeable ball was felt under the skin, tender to the touch and warm. Patient went into urgent care on Monday 1/4/2021 with a confirmed dx of a superficial blood clot. Unknown etiology of whether this is from current birth control or the COVID19 Moderna vaccine.


Changed on 5/14/2021

VAERS ID: 919376 Before After
VAERS Form:2
Age:19.0
Sex:Female
Location:Montana
Vaccinated:2020-12-30
Onset:2021-01-02
Submitted:0000-00-00
Entered:2021-01-04
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Pain of skin, Skin warm, Thrombosis, Limb discomfort, Ultrasound scan abnormal, Limb mass

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? Yes
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Dasetta 1/35, Bile salts OTC, Proair Inhaler PRN
Current Illness: N/a
Preexisting Conditions: Asthma
Allergies: Penicillin Penicillin
Diagnostic Lab Data: 1/4/2021 confirmed with ultrasound of lower extremity.
CDC 'Split Type':

Write-up: Patient received Moderna vaccine, Wednesday 12/30. On Saturday 1/3/2021 patient felt pressure/tightness in lower extremity. When patient touched area, a noticeable ball was felt under the skin, tender to the touch and warm. Patient went into urgent care on Monday 1/4/2021 with a confirmed dx of a superficial blood clot. Unknown etiology of whether this is from current birth control or the COVID19 Moderna vaccine.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=919376&WAYBACKHISTORY=ON


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