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From the 1/14/2022 release of VAERS data:

This is VAERS ID 1333104

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Case Details

VAERS ID: 1333104 (history)  
Form: Version 2.0  
Age: 91.0  
Sex: Female  
Location: Foreign  
Vaccinated:2021-04-01
Onset:2021-04-02
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-05-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 3001442 / 1 - / OT

Administered by: Unknown       Purchased by: ?
Symptoms: Oxygen saturation, Tachycardia, Vomiting
SMQs:, Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Dehydration (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-04-02
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: Medical History/Concurrent Conditions: Disease Parkinson''s; Hypercholesterolaemia; Hypertension; Lung neoplasm surgery; Radiotherapy
Allergies:
Diagnostic Lab Data: Test Date: 20210402; Test Name: Oxygen saturation
CDC Split Type: ITMODERNATX, INC.MOD20211

Write-up: This regulatory authority case was reported by a pharmacist and describes the occurrence of TACHYCARDIA in a 91-year-old female patient who received mRNA-1273 (COVID 19 Vaccine Moderna) (batch no. 3001442) for COVID-19 vaccination. The occurrence of additional non-serious events is detailed below. The patient''s past medical history included Hypercholesterolaemia, Disease Parkinson''s, Hypertension, Lung neoplasm surgery and Radiotherapy. Previously administered products included for an unreported indication: ATORVASTATINA EG, NITROGLICERINA ZENTIVA, AXAGON [ESOMEPRAZOLE MAGNESIUM], LEXOTAN, DIURESIX [TORASEMIDE], TARGIN, ESKIM and PLAVIX. On 01-Apr-2021, the patient received first dose of mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular) 1 dosage form. On 02-Apr-2021, the patient experienced TACHYCARDIA (seriousness criterion death) and VOMITING. The patient died on 02-Apr-2021. The reported cause of death was Vomiting, Oxygen saturation low and Tachycardia. It is unknown if an autopsy was performed. At the time of death, VOMITING, outcome was unknown. DIAGNOSTIC RESULTS (normal ranges are provided in parenthesis if available): On 02-Apr-2021, Oxygen saturation: low. For mRNA-1273 (COVID 19 Vaccine Moderna) (Intramuscular), the reporter did not provide any causality assessments. Treatment information was not provided. Concomitant product use was not provided by the reporter. Based on the current available information and temporal association between the use of the product and the start date of the events, a causal relationship cannot be excluded. Most recent FOLLOW-UP information incorporated above includes: On 06-May-2021: FU added On 10-May-2021: Vaccine Dose number added; Reported Cause(s) of Death: Vomiting; Oxygen saturation low; Tachycardia


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