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This is VAERS ID 1084180

History of Changes from the VAERS Wayback Machine

First Appeared on 3/11/2021

VAERS ID: 1084180
VAERS Form:2
Age:79.0
Sex:Female
Location:Indiana
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Chest pain, Condition aggravated, Death, Pulse absent, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NA
Current Illness: Coronary Artery Disease; COPD
Preexisting Conditions: Coronary Artery Disease; COPD
Allergies: Codeine
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient came with husband to Vaccine clinic today 3/5 for 2nd dose of vaccine. Did well during and immediately after vaccine. Husband states patient has c/o severe chest pressure and pain for several weeks but has refused to come to ER for evaluation. Today, after getting vaccine dose and going to local bank, patient was in passenger side of truck when chest pain started again. Husband begged patient to let him take her to the ER but she said no, I?m fine and I don?t want to go. She then went unresponsive. At a stop light, he was next to a couple of cops who he was able to wave down and proceed to escort them in to ER. Upon arrival to the ER, patient was unresponsive and pulseless. CPR was initiated, 1 defib, and 1mg of epi was given. Return of pulse was obtained, but husband asked for no life support and only comfort measures. Patient was admitted for comfort measures. I do NOT think this was related to her vaccine, but rather the unfortunately end to a sub-acute chest pain patient that declined multiple urgings to seek care. Patient then expired on 3/5/21 at 2037.


Changed on 5/7/2021

VAERS ID: 1084180 Before After
VAERS Form:2
Age:79.0
Sex:Female
Location:Indiana
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Chest pain, Condition aggravated, Death, Pulse absent, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NA
Current Illness: Coronary Artery Disease; COPD
Preexisting Conditions: Coronary Artery Disease; COPD
Allergies: Codeine Codeine
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient came with husband to Vaccine clinic today 3/5 for 2nd dose of vaccine. Did well during and immediately after vaccine. Husband states patient has c/o severe chest pressure and pain for several weeks but has refused to come to ER for evaluation. Today, after getting vaccine dose and going to local bank, patient was in passenger side of truck when chest pain started again. Husband begged patient to let him take her to the ER but she said no, I?m fine and I don?t want to go. She then went unresponsive. At a stop light, he was next to a couple of cops who he was able to wave down and proceed to escort them in to ER. Upon arrival to the ER, patient was unresponsive and pulseless. CPR was initiated, 1 defib, and 1mg of epi was given. Return of pulse was obtained, but husband asked for no life support and only comfort measures. Patient was admitted for comfort measures. I do NOT think this was related to her vaccine, but rather the unfortunately end to a sub-acute chest pain patient that declined multiple urgings to seek care. Patient then expired on 3/5/21 at 2037.


Changed on 5/14/2021

VAERS ID: 1084180 Before After
VAERS Form:2
Age:79.0
Sex:Female
Location:Indiana
Vaccinated:2021-03-05
Onset:2021-03-05
Submitted:0000-00-00
Entered:2021-03-09
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 030A21A / 2 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Chest pain, Condition aggravated, Death, Pulse absent, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-05
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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: NA
Current Illness: Coronary Artery Disease; COPD
Preexisting Conditions: Coronary Artery Disease; COPD
Allergies: Codeine Codeine
Diagnostic Lab Data: None
CDC 'Split Type':

Write-up: Patient came with husband to Vaccine clinic today 3/5 for 2nd dose of vaccine. Did well during and immediately after vaccine. Husband states patient has c/o severe chest pressure and pain for several weeks but has refused to come to ER for evaluation. Today, after getting vaccine dose and going to local bank, patient was in passenger side of truck when chest pain started again. Husband begged patient to let him take her to the ER but she said no, I?m fine and I don?t want to go. She then went unresponsive. At a stop light, he was next to a couple of cops who he was able to wave down and proceed to escort them in to ER. Upon arrival to the ER, patient was unresponsive and pulseless. CPR was initiated, 1 defib, and 1mg of epi was given. Return of pulse was obtained, but husband asked for no life support and only comfort measures. Patient was admitted for comfort measures. I do NOT think this was related to her vaccine, but rather the unfortunately end to a sub-acute chest pain patient that declined multiple urgings to seek care. Patient then expired on 3/5/21 at 2037.

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