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This is VAERS ID 1039090

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1039090
VAERS Form:2
Age:91.0
Sex:Female
Location:South Dakota
Vaccinated:2021-02-02
Onset:2021-02-03
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK RA / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: Anxiety, Blood pressure increased, Cardiac arrest, Coronary artery disease, Death, Malaise, Pain in extremity, Resuscitation, Syncope, Unresponsive to stimuli, Breath sounds abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: GERD (Gastroesophageal Reflux Disease) Hypertension Previous Squamous Cell Skin Cancer
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The patient came to the Emergency Room at approx 3:30 am on 02/03/2021 with pain in right arm (same arm the COVID vaccine had been administered in approx 12 hours earlier) and feeling generally unwell. Patient was concerned about possibility of gout flare or that something was wrong with her arm. Elevated blood pressure was noted; this was attributed to anxiety. She was evaluated, given 500 mg Tylenol, and discharged since the pain was decreasing and blood pressure was stabilized. Patient instructed to follow-up with physician. The next day, on 02/04/2021, the patient arrived at the Emergency Room by ambulance; cardiac arrest was the chief complaint. The patient''s daughter stated the patient had been "feeling generally poor and then suddenly collapsed." Daughter described "gurgling respirations" and being unresponsive. 911 was called, police arrived within 5 minutes and initiated CPR. Epinephrine, atropine, lidocaine and bicarb administered after arrival to Emergency Room. Shockable rhythm never demonstrated. Patient never recovered spontaneous respiration or movement. The death was called at 23:04. Coronary artery disease with cardiac arrest is the cause from the ER records; the coroner is putting COVID-19 vaccination in Part 1 of the death certificate.


Changed on 5/7/2021

VAERS ID: 1039090 Before After
VAERS Form:2
Age:91.0
Sex:Female
Location:South Dakota
Vaccinated:2021-02-02
Onset:2021-02-03
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK RA / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: Anxiety, Blood pressure increased, Cardiac arrest, Coronary artery disease, Death, Malaise, Pain in extremity, Resuscitation, Syncope, Unresponsive to stimuli, Breath sounds abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: GERD (Gastroesophageal Reflux Disease) Hypertension Previous Squamous Cell Skin Cancer
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The patient came to the Emergency Room at approx 3:30 am on 02/03/2021 with pain in right arm (same arm the COVID vaccine had been administered in approx 12 hours earlier) and feeling generally unwell. Patient was concerned about possibility of gout flare or that something was wrong with her arm. Elevated blood pressure was noted; this was attributed to anxiety. She was evaluated, given 500 mg Tylenol, and discharged since the pain was decreasing and blood pressure was stabilized. Patient instructed to follow-up with physician. The next day, on 02/04/2021, the patient arrived at the Emergency Room by ambulance; cardiac arrest was the chief complaint. The patient''s daughter stated the patient had been "feeling generally poor and then suddenly collapsed." Daughter described "gurgling respirations" and being unresponsive. 911 was called, police arrived within 5 minutes and initiated CPR. Epinephrine, atropine, lidocaine and bicarb administered after arrival to Emergency Room. Shockable rhythm never demonstrated. Patient never recovered spontaneous respiration or movement. The death was called at 23:04. Coronary artery disease with cardiac arrest is the cause from the ER records; the coroner is putting COVID-19 vaccination in Part 1 of the death certificate.


Changed on 5/14/2021

VAERS ID: 1039090 Before After
VAERS Form:2
Age:91.0
Sex:Female
Location:South Dakota
Vaccinated:2021-02-02
Onset:2021-02-03
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA - / UNK RA / SYR

Administered by: Unknown      Purchased by: ??
Symptoms: Anxiety, Blood pressure increased, Cardiac arrest, Coronary artery disease, Death, Malaise, Pain in extremity, Resuscitation, Syncope, Unresponsive to stimuli, Breath sounds abnormal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-04
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: GERD (Gastroesophageal Reflux Disease) Hypertension Previous Squamous Cell Skin Cancer
Allergies:
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The patient came to the Emergency Room at approx 3:30 am on 02/03/2021 with pain in right arm (same arm the COVID vaccine had been administered in approx 12 hours earlier) and feeling generally unwell. Patient was concerned about possibility of gout flare or that something was wrong with her arm. Elevated blood pressure was noted; this was attributed to anxiety. She was evaluated, given 500 mg Tylenol, and discharged since the pain was decreasing and blood pressure was stabilized. Patient instructed to follow-up with physician. The next day, on 02/04/2021, the patient arrived at the Emergency Room by ambulance; cardiac arrest was the chief complaint. The patient''s daughter stated the patient had been "feeling generally poor and then suddenly collapsed." Daughter described "gurgling respirations" and being unresponsive. 911 was called, police arrived within 5 minutes and initiated CPR. Epinephrine, atropine, lidocaine and bicarb administered after arrival to Emergency Room. Shockable rhythm never demonstrated. Patient never recovered spontaneous respiration or movement. The death was called at 23:04. Coronary artery disease with cardiac arrest is the cause from the ER records; the coroner is putting COVID-19 vaccination in Part 1 of the death certificate.

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