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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 (1 vaccine) | 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.
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