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This is VAERS ID 1125936

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1125936
VAERS Form:2
Age:86.0
Sex:Male
Location:Indiana
Vaccinated:2021-03-20
Onset:2021-03-21
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, Pulmonary congestion, Resuscitation, Ventricular fibrillation, Ventricular tachycardia, Vomiting, Feeding tube user

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-21
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: 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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