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This is VAERS ID 997677

History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 997677
VAERS Form:2
Age:94.0
Sex:Female
Location:Wisconsin
Vaccinated:2021-02-01
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 - / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Blood pressure increased, Cerebrovascular accident, Death, Heart rate increased, Loss of consciousness, Posturing, Pulmonary embolism, General physical health deterioration, Coma scale abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-03
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: Losartan, dilTIAZem, Omeprazole, Ipratropium-Albuterol Solution, Perforomist Nebulization Solution, Furosemide, Budesonide Suspension, Levothyroxine , PARoxetine, Melatonin, Ibuprofen, Aspirin, Cholecalciferol, Docusate Sodium Capsule, ARIP
Current Illness:
Preexisting Conditions: PULMONARY FIBROSIS, CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, HYPOTHYROIDISM, HYPERTENSION, IRON DEFICIENCY ANEMIAS
Allergies: Amlodipine, Ciprofloxacin, Citalopram, Codeine, Penicillin, traMADol, Spiriva Respimat, Sulfa Antibiotics
Diagnostic Lab Data: Family declined treatment or diagnostic testing. Dr signed comfort orders, verbalized probable PE or stroke
CDC 'Split Type':

Write-up: Rapid decline in health status, Elevated BP&P, posturing, loss of consciousness, Glasgow coma Scale 4 starting 2/1/2021, Deceased 2/3/21


Changed on 5/7/2021

VAERS ID: 997677 Before After
VAERS Form:2
Age:94.0
Sex:Female
Location:Wisconsin
Vaccinated:2021-02-01
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 - / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Blood pressure increased, Cerebrovascular accident, Death, Heart rate increased, Loss of consciousness, Posturing, Pulmonary embolism, General physical health deterioration, Coma scale abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-03
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: Losartan, dilTIAZem, Omeprazole, Ipratropium-Albuterol Solution, Perforomist Nebulization Solution, Furosemide, Budesonide Suspension, Levothyroxine , PARoxetine, Melatonin, Ibuprofen, Aspirin, Cholecalciferol, Docusate Sodium Capsule, ARIP
Current Illness:
Preexisting Conditions: PULMONARY FIBROSIS, CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, HYPOTHYROIDISM, HYPERTENSION, IRON DEFICIENCY ANEMIAS
Allergies: Amlodipine, Ciprofloxacin, Citalopram, Codeine, Penicillin, traMADol, Spiriva Respimat, Sulfa Antibiotics Antibiotics
Diagnostic Lab Data: Family declined treatment or diagnostic testing. Dr signed comfort orders, verbalized probable PE or stroke
CDC 'Split Type':

Write-up: Rapid decline in health status, Elevated BP&P, posturing, loss of consciousness, Glasgow coma Scale 4 starting 2/1/2021, Deceased 2/3/21


Changed on 5/14/2021

VAERS ID: 997677 Before After
VAERS Form:2
Age:94.0
Sex:Female
Location:Wisconsin
Vaccinated:2021-02-01
Onset:2021-02-01
Submitted:0000-00-00
Entered:2021-02-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 031L20A / 1 - / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Blood pressure increased, Cerebrovascular accident, Death, Heart rate increased, Loss of consciousness, Posturing, Pulmonary embolism, General physical health deterioration, Coma scale abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-03
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: Losartan, dilTIAZem, Omeprazole, Ipratropium-Albuterol Solution, Perforomist Nebulization Solution, Furosemide, Budesonide Suspension, Levothyroxine , PARoxetine, Melatonin, Ibuprofen, Aspirin, Cholecalciferol, Docusate Sodium Capsule, ARIP
Current Illness:
Preexisting Conditions: PULMONARY FIBROSIS, CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, HYPOTHYROIDISM, HYPERTENSION, IRON DEFICIENCY ANEMIAS
Allergies: Amlodipine, Ciprofloxacin, Citalopram, Codeine, Penicillin, traMADol, Spiriva Respimat, Sulfa Antibiotics Antibiotics
Diagnostic Lab Data: Family declined treatment or diagnostic testing. Dr signed comfort orders, verbalized probable PE or stroke
CDC 'Split Type':

Write-up: Rapid decline in health status, Elevated BP&P, posturing, loss of consciousness, Glasgow coma Scale 4 starting 2/1/2021, Deceased 2/3/21

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