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This is VAERS ID 1333104

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History of Changes from the VAERS Wayback Machine

First Appeared on 7/9/2021

VAERS ID: 1333104
VAERS Form:2
Age:91.0
Sex:Female
Location:Foreign
Vaccinated:2021-04-01
Onset:2021-04-02
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

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-04-02
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? 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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