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This is VAERS ID 1005499

History of Changes from the VAERS Wayback Machine

First Appeared on 2/12/2021

VAERS ID: 1005499
VAERS Form:2
Age:80.0
Sex:Female
Location:Unknown
Vaccinated:2021-02-02
Onset:2021-02-02
Submitted:0000-00-00
Entered:2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 2 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Atrial fibrillation, Blood lactic acid, Dizziness, Dyspnoea, Hypotension, Presyncope, Syncope, Tachypnoea, Vomiting, White blood cell count normal, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-02-04
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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen calcium carbonate/vitamin D3 fluoxetine ibuprofen cholecalciferol
Current Illness:
Preexisting Conditions: depression, hearing difficulties, osteoporosis, hyperlipidemia, PVD, breast cancer in situ, hypertension, aortic aneurysm
Allergies: Adhesive tape-silicone celecoxib hydrocodone-acetaminophen pravastatin
Diagnostic Lab Data: Lactic Acid 5.6 on admission, WBC 9.2 on admission
CDC 'Split Type':

Write-up: Moderna Vaccine Lot 029K20A Patient received second dose of vaccine on 2/2/21. Within 30 minutes patient had a near syncopal episode. She felt lightheaded and shortly after had episode of nonbloody vomiting. Hypotensive 81/69 and started on levophed. Alert and orientated. Lungs clear, abdomen benign on admission. Patient had no reaction when received first dose of the vaccine. Patient developed worsening shortness of breath, tachypnea, Afib with RVR, hypotension and required intubation and multiple pressors.


Changed on 5/7/2021

VAERS ID: 1005499 Before After
VAERS Form:2
Age:80.0
Sex:Female
Location:Unknown
Vaccinated:2021-02-02
Onset:2021-02-02
Submitted:0000-00-00
Entered:2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 2 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Atrial fibrillation, Blood lactic acid, Dizziness, Dyspnoea, Hypotension, Presyncope, Syncope, Tachypnoea, Vomiting, White blood cell count normal, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-02-04
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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen calcium carbonate/vitamin D3 fluoxetine ibuprofen cholecalciferol
Current Illness:
Preexisting Conditions: depression, hearing difficulties, osteoporosis, hyperlipidemia, PVD, breast cancer in situ, hypertension, aortic aneurysm
Allergies: Adhesive tape-silicone celecoxib hydrocodone-acetaminophen pravastatin pravastatin
Diagnostic Lab Data: Lactic Acid 5.6 on admission, WBC 9.2 on admission
CDC 'Split Type':

Write-up: Moderna Vaccine Lot 029K20A Patient received second dose of vaccine on 2/2/21. Within 30 minutes patient had a near syncopal episode. She felt lightheaded and shortly after had episode of nonbloody vomiting. Hypotensive 81/69 and started on levophed. Alert and orientated. Lungs clear, abdomen benign on admission. Patient had no reaction when received first dose of the vaccine. Patient developed worsening shortness of breath, tachypnea, Afib with RVR, hypotension and required intubation and multiple pressors.


Changed on 5/14/2021

VAERS ID: 1005499 Before After
VAERS Form:2
Age:80.0
Sex:Female
Location:Unknown
Vaccinated:2021-02-02
Onset:2021-02-02
Submitted:0000-00-00
Entered:2021-02-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 029K20A / 2 UN / IM

Administered by: Private      Purchased by: ??
Symptoms: Atrial fibrillation, Blood lactic acid, Dizziness, Dyspnoea, Hypotension, Presyncope, Syncope, Tachypnoea, Vomiting, White blood cell count normal, Endotracheal intubation

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2021-02-04
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: 3     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Acetaminophen calcium carbonate/vitamin D3 fluoxetine ibuprofen cholecalciferol
Current Illness:
Preexisting Conditions: depression, hearing difficulties, osteoporosis, hyperlipidemia, PVD, breast cancer in situ, hypertension, aortic aneurysm
Allergies: Adhesive tape-silicone celecoxib hydrocodone-acetaminophen pravastatin pravastatin
Diagnostic Lab Data: Lactic Acid 5.6 on admission, WBC 9.2 on admission
CDC 'Split Type':

Write-up: Moderna Vaccine Lot 029K20A Patient received second dose of vaccine on 2/2/21. Within 30 minutes patient had a near syncopal episode. She felt lightheaded and shortly after had episode of nonbloody vomiting. Hypotensive 81/69 and started on levophed. Alert and orientated. Lungs clear, abdomen benign on admission. Patient had no reaction when received first dose of the vaccine. Patient developed worsening shortness of breath, tachypnea, Afib with RVR, hypotension and required intubation and multiple pressors.

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