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From the 5/7/2021 release of VAERS data:

This is VAERS ID 1125936



Case Details

VAERS ID: 1125936 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Male  
Location: Indiana  
Vaccinated:2021-03-20
Onset:2021-03-21
   Days after vaccination:1
Submitted: 0000-00-00
Entered: 2021-03-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 040A21A / 1 UN / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Cheyne-Stokes respiration, Cough, Dyspnoea, Feeding tube user, Pulmonary congestion, Resuscitation, Ventricular fibrillation, Ventricular tachycardia, Vomiting
SMQs:, Torsade de pointes/QT prolongation (narrow), Cardiac failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Ventricular tachyarrhythmias (narrow), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Torsade de pointes, shock-associated conditions (narrow), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-21
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Piperacillin-Tazobactam in Dex Solution 3-0.375 GM/50ML Use 3.375 gram intravenously every 8 hours for Staph infection of blood for 13 Days Lovenox Solution (Enoxaparin Sodium) Inject 70 mg subcutaneously one time a day for DVT prevention P
Current Illness: Cough, emesis and chronic health conditions as listed below
Preexisting Conditions: FRACTURE OF UNSPECIFIED PART OF NECK OF RIGHT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING , ENCOUNTER FOR OTHER ORTHOPEDIC AFTERCARE, ACUTE RESPIRATORY FAILURE WITH HYPOXIA , UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE, UNSPECIFIED STAPHYLOCOCCUS AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE, DYSPHAGIA, ORAL PHASE, PRESSURE ULCER OF SACRAL REGION, STAGE 4, MUSCLE WEAKNESS (GENERALIZED) , NEED FOR ASSISTANCE WITH PERSONAL CARE, DYSPHAGIA, OROPHARYNGEAL PHASE , COGNITIVE COMMUNICATION DEFICIT, CHRONIC ATRIAL FIBRILLATION, UNSPECIFIED , TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, ESSENTIAL (PRIMARY) HYPERTENSION , MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, MILD, PURE HYPERCHOLESTEROLEMIA, UNSPECIFIED, PRESENCE OF CARDIAC PACEMAKER , LONG TERM (CURRENT) USE OF ANTICOAGULANTS, HYPOTHYROIDISM, UNSPECIFIED
Allergies: NKA
Diagnostic Lab Data:
CDC Split Type:

Write-up: 3-21-21 at 5:35am - Intermittent coughing during HS. Afebrile. Upper lung fields noted congestion; clearing when coughing/turned repositioned per staff, Afebrile. 3-21-21 at 9:30am - In residents room repositioning him, resident vomited tube feeding. Turned him on his side and swept out his mouth. Tube feeding pump turned off. Breathing became labored. Second nurse placed non-rebreather mask on him. Called 911 to take resident to hospital. 3-21-21 9:45am EMS now at bedside. Pulse palpable, Cheyne Stokes respirations. O2 on per non-rebreather mask. EMS assessed resident- now in VT/VF CPR initiated. Code cart placed outside of door. 3-21-21 10:00am Resident transferred out to Rig with an organized heart rhythm. Dr. ( on call for Dr.) notified of event and transport to hospital.


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