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This is VAERS ID 991997

History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 991997
VAERS Form:2
Age:71.0
Sex:Female
Location:Minnesota
Vaccinated:2021-01-28
Onset:2021-01-30
Submitted:0000-00-00
Entered:2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood glucose increased, Blood potassium increased, Cardiogenic shock, Cold sweat, Death, Nausea, Sepsis, Vomiting, White blood cell count increased, Troponin increased, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-30
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol, Levemir, Humalog, Trazodone, Prozac, Metoprolol, Eliquis, Plavix, Atorvastatin, Pantoprazole, Dialyvite, Renagel
Current Illness: COVID + diagnosis (12/17/2020) ASYMPTOMATIC Multiple oral extractions completed by dentist on 1/26/2020 ESRD (on 3x week dialysis-last date of dialysis 1/29/2020)
Preexisting Conditions: ESRD, Diabetic, Heart Disease, Vascular Disease, HTN,
Allergies: Bactrim/Sulfa, Cyclobenzaprine, Fentanyl, Gabapentin, Lisinopril, Metoprolol, Primidone
Diagnostic Lab Data: Multiple test completed during course of ER and hospital stay WBC 16.8, K+ 6.1, Serial Troponins 363, 444, 578
CDC 'Split Type':

Write-up: Resident c/o nausea evening of 1/29 (nausea common for her post dialysis), had a large emesis at approx 2220, 0030 (unusual for resident to vomit)- received Zofran per order. Skin cool and damp, Blood sugar 147 (checked due to h/o diabetes and poor intake). At approx 230am Blood pressured checked and noted to be 52/29. Resident transferred to ER, intubated and transferred to higher level of care where she passed away on 1/30 at 736pm. Resident''s medical notes indicated likely shock, cardiogenic in nature, sepsis (source unknown) along with a multitude of other co-morbidities that resident has.


Changed on 5/7/2021

VAERS ID: 991997 Before After
VAERS Form:2
Age:71.0
Sex:Female
Location:Minnesota
Vaccinated:2021-01-28
Onset:2021-01-30
Submitted:0000-00-00
Entered:2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood glucose increased, Blood potassium increased, Cardiogenic shock, Cold sweat, Death, Nausea, Sepsis, Vomiting, White blood cell count increased, Troponin increased, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-30
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol, Levemir, Humalog, Trazodone, Prozac, Metoprolol, Eliquis, Plavix, Atorvastatin, Pantoprazole, Dialyvite, Renagel
Current Illness: COVID + diagnosis (12/17/2020) ASYMPTOMATIC Multiple oral extractions completed by dentist on 1/26/2020 ESRD (on 3x week dialysis-last date of dialysis 1/29/2020)
Preexisting Conditions: ESRD, Diabetic, Heart Disease, Vascular Disease, HTN,
Allergies: Bactrim/Sulfa, Cyclobenzaprine, Fentanyl, Gabapentin, Lisinopril, Metoprolol, Primidone Primidone
Diagnostic Lab Data: Multiple test completed during course of ER and hospital stay WBC 16.8, K+ 6.1, Serial Troponins 363, 444, 578
CDC 'Split Type':

Write-up: Resident c/o nausea evening of 1/29 (nausea common for her post dialysis), had a large emesis at approx 2220, 0030 (unusual for resident to vomit)- received Zofran per order. Skin cool and damp, Blood sugar 147 (checked due to h/o diabetes and poor intake). At approx 230am Blood pressured checked and noted to be 52/29. Resident transferred to ER, intubated and transferred to higher level of care where she passed away on 1/30 at 736pm. Resident''s medical notes indicated likely shock, cardiogenic in nature, sepsis (source unknown) along with a multitude of other co-morbidities that resident has.


Changed on 5/14/2021

VAERS ID: 991997 Before After
VAERS Form:2
Age:71.0
Sex:Female
Location:Minnesota
Vaccinated:2021-01-28
Onset:2021-01-30
Submitted:0000-00-00
Entered:2021-02-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029L20A / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood glucose increased, Blood potassium increased, Cardiogenic shock, Cold sweat, Death, Nausea, Sepsis, Vomiting, White blood cell count increased, Troponin increased, Endotracheal intubation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-30
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: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Tylenol, Levemir, Humalog, Trazodone, Prozac, Metoprolol, Eliquis, Plavix, Atorvastatin, Pantoprazole, Dialyvite, Renagel
Current Illness: COVID + diagnosis (12/17/2020) ASYMPTOMATIC Multiple oral extractions completed by dentist on 1/26/2020 ESRD (on 3x week dialysis-last date of dialysis 1/29/2020)
Preexisting Conditions: ESRD, Diabetic, Heart Disease, Vascular Disease, HTN,
Allergies: Bactrim/Sulfa, Cyclobenzaprine, Fentanyl, Gabapentin, Lisinopril, Metoprolol, Primidone Primidone
Diagnostic Lab Data: Multiple test completed during course of ER and hospital stay WBC 16.8, K+ 6.1, Serial Troponins 363, 444, 578
CDC 'Split Type':

Write-up: Resident c/o nausea evening of 1/29 (nausea common for her post dialysis), had a large emesis at approx 2220, 0030 (unusual for resident to vomit)- received Zofran per order. Skin cool and damp, Blood sugar 147 (checked due to h/o diabetes and poor intake). At approx 230am Blood pressured checked and noted to be 52/29. Resident transferred to ER, intubated and transferred to higher level of care where she passed away on 1/30 at 736pm. Resident''s medical notes indicated likely shock, cardiogenic in nature, sepsis (source unknown) along with a multitude of other co-morbidities that resident has.

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