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This is VAERS ID 940866

History of Changes from the VAERS Wayback Machine

First Appeared on 1/15/2021

VAERS ID: 940866
VAERS Form:2
Age:75.0
Sex:Male
Location:South Carolina
Vaccinated:2021-01-07
Onset:2021-01-09
Submitted:0000-00-00
Entered:2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Cardio-respiratory arrest, Death, Pulse absent, Resuscitation, Abnormal behaviour

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-09
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: Amlodipine, ASA, Atorvastatin, Baclofen, Risperidone, Levothyr
Current Illness: None
Preexisting Conditions: Hypothyroidism, Bipolar, Profound ID, HTN, Osteopenia, dysphagia, aphasia, TBI as a young adult,Muscle spasm, Hernia
Allergies: Loxapine, Thioridazine
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found "acting abnormal" on 1/9/2021 at 1215. VS HR 20-30''s. EMS activated. EMS arrived and patient was found pulseless in PEA/ asystole, CPR and ACLS initiated and then transported to the MC. Unsuccessful resuscitation and expired on 1/09/2021 at 1348. Clinical impression Cardiopulmonary arrest.


Changed on 5/7/2021

VAERS ID: 940866 Before After
VAERS Form:2
Age:75.0
Sex:Male
Location:South Carolina
Vaccinated:2021-01-07
Onset:2021-01-09
Submitted:0000-00-00
Entered:2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Cardio-respiratory arrest, Death, Pulse absent, Resuscitation, Abnormal behaviour

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-09
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: Amlodipine, ASA, Atorvastatin, Baclofen, Risperidone, Levothyr
Current Illness: None
Preexisting Conditions: Hypothyroidism, Bipolar, Profound ID, HTN, Osteopenia, dysphagia, aphasia, TBI as a young adult,Muscle spasm, Hernia
Allergies: Loxapine, Thioridazine Thioridazine
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found "acting abnormal" on 1/9/2021 at 1215. VS HR 20-30''s. EMS activated. EMS arrived and patient was found pulseless in PEA/ asystole, CPR and ACLS initiated and then transported to the MC. Unsuccessful resuscitation and expired on 1/09/2021 at 1348. Clinical impression Cardiopulmonary arrest.


Changed on 5/14/2021

VAERS ID: 940866 Before After
VAERS Form:2
Age:75.0
Sex:Male
Location:South Carolina
Vaccinated:2021-01-07
Onset:2021-01-09
Submitted:0000-00-00
Entered:2021-01-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011L20A / 1 - / IM

Administered by: Other      Purchased by: ??
Symptoms: Cardiac arrest, Cardio-respiratory arrest, Death, Pulse absent, Resuscitation, Abnormal behaviour

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-09
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: Amlodipine, ASA, Atorvastatin, Baclofen, Risperidone, Levothyr
Current Illness: None
Preexisting Conditions: Hypothyroidism, Bipolar, Profound ID, HTN, Osteopenia, dysphagia, aphasia, TBI as a young adult,Muscle spasm, Hernia
Allergies: Loxapine, Thioridazine Thioridazine
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Patient was found "acting abnormal" on 1/9/2021 at 1215. VS HR 20-30''s. EMS activated. EMS arrived and patient was found pulseless in PEA/ asystole, CPR and ACLS initiated and then transported to the MC. Unsuccessful resuscitation and expired on 1/09/2021 at 1348. Clinical impression Cardiopulmonary arrest.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=940866&WAYBACKHISTORY=ON

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