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From the 5/7/2021 release of VAERS data (an older release, current is 1/14/2022):

This is VAERS ID 981912

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Case Details

VAERS ID: 981912 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Female  
Location: California  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Unknown       Purchased by: ?
Symptoms: Angiogram pulmonary abnormal, Cardiac arrest, Chest pain, Cold sweat, Death, Endotracheal intubation, Hypotension, Laboratory test, Pallor, Pulmonary embolism
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Angioedema (broad), Neuroleptic malignant syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Embolic and thrombotic events, venous (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (broad), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Respiratory failure (broad), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-27
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: albuterol, fluticasone nasal spray, hydrochlorothiazide, losartan
Current Illness:
Preexisting Conditions: hypertension
Allergies: none
Diagnostic Lab Data: 1/27 in the ED patient underwent a CTA chest to reveal PE, basic labs, alteplase 100 mg, amiodarone 150 mg followed by infusion, was intubated with rocuronium, and placed on a norepinephrine drip.
CDC Split Type:

Write-up: Patient presented to the Emergency Department complaining of chest pain, pale, cool diaphoretic, and hypotensive. The patient was discovered to have a large saddle pulmonary embolism, went into cardiac arrest and expired. Of note, the patient received her second Moderna COVID vaccine on 1/23, which would place her first one approximately 12/25 if she received them at the appropriate interval. This information is from the patient''s daughter and the ED record, the information is not available in CAIR. Per the daughter, the patient started feeling ill on 1/21, improved on 1/25, and then acutely worsened on 1/27, resulting in the ED visit.

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