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From the 5/7/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 920368



Case Details

VAERS ID: 920368 (history)  
Form: Version 2.0  
Age: 92.0  
Sex: Female  
Location: Indiana  
Vaccinated:2020-12-29
Onset:2020-12-30
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 026L20A / 1 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood creatinine increased, Blood urea increased, Body temperature increased, Chest X-ray abnormal, Decreased appetite, Dyspnoea, Erythema, Full blood count, Hospice care, Influenza virus test negative, Lung infiltration, Metabolic function test, Respiratory rate increased, Vital functions abnormal, White blood cell count increased
SMQs:, Rhabdomyolysis/myopathy (broad), Acute renal failure (broad), Anaphylactic reaction (narrow), Interstitial lung disease (narrow), Neuroleptic malignant syndrome (broad), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Eosinophilic pneumonia (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (narrow), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-01
   Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetaminophen, Atenolol, Colace, Lisinopril, Mirtazapine, Omeprazole, Simvastatin, Vitamin D3
Current Illness: F03.90 Unspecified dementia without behavioral disturbance E78.5 Hyperlipidemia, unspecified K21.9 Gastro-esophageal reflux disease without esophagitis I10 Essential (primary) hypertension Z74.09 Other reduced mobility M62.81 Muscle weakness (generalized) R13.12 Dysphagia, oropharyngeal phase R26.81 Unsteadiness on feet R27.8 Other lack of coordination R41.841 Cognitive communication deficit R54 Age-related physical debility D53.9 Nutritional anemia, unspecified R29.6 Repeated falls M13.80 Other specified arthritis, unspecified site M25.512 Pain in left shoulder M19.012 Primary osteoarthritis, left shoulder K59.09 Other constipation R26.89 Other abnormalities of gait and mobility R63.8 Other symptoms and signs concerning food and fluid intake M85.89 Other specified disorders of bone density and structure, multiple sites Note: Osteopenia M24.512 Contracture, left shoulder J43.9 Emphysema, unspecified
Preexisting Conditions: U07.1 2019-nCoV acute respiratory disease (Primary) F03.90 Unspecified dementia without behavioral disturbance E78.5 Hyperlipidemia, unspecified K21.9 Gastro-esophageal reflux disease without esophagitis I10 Essential (primary) hypertension Z74.09 Other reduced mobility M62.81 Muscle weakness (generalized) R13.12 Dysphagia, oropharyngeal phase R26.81 Unsteadiness on feet R27.8 Other lack of coordination R41.841 Cognitive communication deficit R54 Age-related physical debility D53.9 Nutritional anemia, unspecified R29.6 Repeated falls M13.80 Other specified arthritis, unspecified site M25.512 Pain in left shoulder M19.012 Primary osteoarthritis, left shoulder K59.09 Other constipation R26.89 Other abnormalities of gait and mobility R63.8 Other symptoms and signs concerning food and fluid intake M85.89 Other specified disorders of bone density and structure, multiple sites Note: Osteopenia M24.512 Contracture, left shoulder J43.9 Emphysema, unspecified
Allergies: quinine sulfate
Diagnostic Lab Data: Influenza Swab: 12/30/20-Negative Results CBC: 12/30/20 showed WBC of 14.1 (H) CMP: 12/30/20 showed BUN: 113 (H); Creatinine 2.7 (H) CXR: 12/30/20 showed: Conclusion: A mild left lower lung infiltrate
CDC Split Type:

Write-up: 12/30/2020 07:02 AM Resident noted to have some redness in face and respiration were fast. Resident vital signs were abnormal except blood pressure. Temp at the time was 102.0 F taken temporal. Resident respirations were 22 labored at times. Pulse is 105 and pulse ox 94% on room air. Resident is made comfortable in bed. Notified triage of change in condition also made triage aware of resident receiving Covid vaccination yesterday morning. Resident appetite and fluid consumption has been poor for few days. 12/30/2020 07:32 AM Received order from agency to administer Acetaminophen 650mg suppos rectally due to resident not wanting to swallow anything including fluids, medications and food. This writer administered medication as NP ordered. Will monitor for effectiveness and adverse effects if any. 12/30/2020 08:41 AM Received new orders to obtain Flu swab, obtain CBC and BMP, and Chest Xray all to be obtained today. Notified family of resident having temperature and vital signs excluding b/p that was abnormal. Family was thankful for call and inierated to nurse that family does not want resident sent to hospital. Did educate family on benefits of Hospice services, but family persistant on continued daily care provided by nursing staff. Requests visits if decline continues. Family assured if resident continues to decline, facility will accomandate resident family to be able to be at bedside when time comes to do so. NP ordered IVF and IV Levaquin on 12/31/20. Family chose at that time to sign for Hospice services and not have resident provided with IVF or IV Antibiotics


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210507&IDNUMBER=920368

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