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This is VAERS ID 1028101

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1028101
VAERS Form:2
Age:70.0
Sex:Male
Location:Indiana
Vaccinated:2021-01-22
Onset:2021-01-23
Submitted:0000-00-00
Entered:2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Blood gases abnormal, Cardio-respiratory arrest, Death, Electrocardiogram abnormal, Hypoxia, Metabolic acidosis, Myocardial ischaemia, Pain in extremity, Pulmonary embolism, Resuscitation, Syncope, Peripheral swelling, Pulseless electrical activity, Metabolic function test normal, Troponin normal, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-23
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: Allopurinol 400mg Daily
Current Illness: Hyperuricemia Renal stone
Preexisting Conditions: Hyperuricemia Renal Stones
Allergies: Shellfish
Diagnostic Lab Data: ABG'' Met acidosis hypoxia EKG; Inf ischemia BMP; normal Troponin; Normal Covi 19 ;Neg
CDC 'Split Type':

Write-up: Pt develops left leg pain The day after vaccination in AM subsequently drove approximately 150 miles On his way back stopped at his brothers place for lunch. He then collapsed coning down the steps, EMS started CPR. took him to ER Resuscitated briefly but went into CardioPulm Arrest again and PEA Resucitaion for aprox 1 hour but was unsuccessful. Noted to have Left leg more swollen than Right by 3 to 4 CM presumed to have died from massive Pulmonary embolism and inferior wall myocardial ischemia


Changed on 5/7/2021

VAERS ID: 1028101 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:Indiana
Vaccinated:2021-01-22
Onset:2021-01-23
Submitted:0000-00-00
Entered:2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Blood gases abnormal, Cardio-respiratory arrest, Death, Electrocardiogram abnormal, Hypoxia, Metabolic acidosis, Myocardial ischaemia, Pain in extremity, Pulmonary embolism, Resuscitation, Syncope, Peripheral swelling, Pulseless electrical activity, Metabolic function test normal, Troponin normal, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-23
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: Allopurinol 400mg Daily
Current Illness: Hyperuricemia Renal stone
Preexisting Conditions: Hyperuricemia Renal Stones
Allergies: Shellfish Shellfish
Diagnostic Lab Data: ABG'' Met acidosis hypoxia EKG; Inf ischemia BMP; normal Troponin; Normal Covi 19 ;Neg
CDC 'Split Type':

Write-up: Pt develops left leg pain The day after vaccination in AM subsequently drove approximately 150 miles On his way back stopped at his brothers place for lunch. He then collapsed coning down the steps, EMS started CPR. took him to ER Resuscitated briefly but went into CardioPulm Arrest again and PEA Resucitaion for aprox 1 hour but was unsuccessful. Noted to have Left leg more swollen than Right by 3 to 4 CM presumed to have died from massive Pulmonary embolism and inferior wall myocardial ischemia


Changed on 5/14/2021

VAERS ID: 1028101 Before After
VAERS Form:2
Age:70.0
Sex:Male
Location:Indiana
Vaccinated:2021-01-22
Onset:2021-01-23
Submitted:0000-00-00
Entered:2021-02-13
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / UNK LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Blood gases abnormal, Cardio-respiratory arrest, Death, Electrocardiogram abnormal, Hypoxia, Metabolic acidosis, Myocardial ischaemia, Pain in extremity, Pulmonary embolism, Resuscitation, Syncope, Peripheral swelling, Pulseless electrical activity, Metabolic function test normal, Troponin normal, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-23
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: Allopurinol 400mg Daily
Current Illness: Hyperuricemia Renal stone
Preexisting Conditions: Hyperuricemia Renal Stones
Allergies: Shellfish Shellfish
Diagnostic Lab Data: ABG'' Met acidosis hypoxia EKG; Inf ischemia BMP; normal Troponin; Normal Covi 19 ;Neg
CDC 'Split Type':

Write-up: Pt develops left leg pain The day after vaccination in AM subsequently drove approximately 150 miles On his way back stopped at his brothers place for lunch. He then collapsed coning down the steps, EMS started CPR. took him to ER Resuscitated briefly but went into CardioPulm Arrest again and PEA Resucitaion for aprox 1 hour but was unsuccessful. Noted to have Left leg more swollen than Right by 3 to 4 CM presumed to have died from massive Pulmonary embolism and inferior wall myocardial ischemia

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