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This is VAERS ID 1036479

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1036479
VAERS Form:2
Age:77.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-03
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Acute myocardial infarction, Blood creatinine increased, Blood lactic acid decreased, Blood urea increased, Cardiac failure congestive, Chest X-ray abnormal, Computerised tomogram normal, Death, Dyspnoea, Fall, Glomerular filtration rate decreased, Hypoxia, Platelet count decreased, General physical health deterioration, Contusion, Brain natriuretic peptide increased, Troponin I increased, Blood alkaline phosphatase increased, Abdominal injury, Chest injury, Bilevel positive airway pressure, Lung opacity, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-08
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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allegra daily as needed; Ambien 5mg daily at bedtime; Aspirin 81 daily; Digoxin daily; hydrocodone-acetaminophen 5-325 as needed pain; Pravastatin 20 daily; ramipril 2.5 daily; zoloft 200 daily
Current Illness: Fell 2/4 and struck abdomen and ribs with large amount bruising Brought to ER 2/7 due to increased shortness of breath since COVID vaccine. Patient was admitted with CHF, hypoxia, possible aspiration pneumonia; NSTEMI (refused transfer for cardiology).
Preexisting Conditions: Dementia; CABG; HTN; MI; esophageal varices; Former smoker; liver cirrhosis; absent kidney
Allergies: Sulfa and vicodin
Diagnostic Lab Data: 2/7-2/8 hospital labs: BUN 29 Cr 1.43 GFR 48 Alk Phos 151 Lactic Acid 2.5 BNP 203 Troponin I 1.28 platelet count 78 COVID-19 Rapid Negative. Chest x-ray with hazy airspace opacities, CT Negative.
CDC 'Split Type':

Write-up: Fall 2/4 hospital admission 2/7/21 with death on 2/8/2021. Patient continued to decline on Bipap he was a DNR/DNI and family decided on comfort measures and he expired 2/8/2021.


Changed on 5/7/2021

VAERS ID: 1036479 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-03
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Acute myocardial infarction, Blood creatinine increased, Blood lactic acid decreased, Blood urea increased, Cardiac failure congestive, Chest X-ray abnormal, Computerised tomogram normal, Death, Dyspnoea, Fall, Glomerular filtration rate decreased, Hypoxia, Platelet count decreased, General physical health deterioration, Contusion, Brain natriuretic peptide increased, Troponin I increased, Blood alkaline phosphatase increased, Abdominal injury, Chest injury, Bilevel positive airway pressure, Lung opacity, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-08
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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allegra daily as needed; Ambien 5mg daily at bedtime; Aspirin 81 daily; Digoxin daily; hydrocodone-acetaminophen 5-325 as needed pain; Pravastatin 20 daily; ramipril 2.5 daily; zoloft 200 daily
Current Illness: Fell 2/4 and struck abdomen and ribs with large amount bruising Brought to ER 2/7 due to increased shortness of breath since COVID vaccine. Patient was admitted with CHF, hypoxia, possible aspiration pneumonia; NSTEMI (refused transfer for cardiology).
Preexisting Conditions: Dementia; CABG; HTN; MI; esophageal varices; Former smoker; liver cirrhosis; absent kidney
Allergies: Sulfa and vicodin vicodin
Diagnostic Lab Data: 2/7-2/8 hospital labs: BUN 29 Cr 1.43 GFR 48 Alk Phos 151 Lactic Acid 2.5 BNP 203 Troponin I 1.28 platelet count 78 COVID-19 Rapid Negative. Chest x-ray with hazy airspace opacities, CT Negative.
CDC 'Split Type':

Write-up: Fall 2/4 hospital admission 2/7/21 with death on 2/8/2021. Patient continued to decline on Bipap he was a DNR/DNI and family decided on comfort measures and he expired 2/8/2021.


Changed on 5/14/2021

VAERS ID: 1036479 Before After
VAERS Form:2
Age:77.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-03
Onset:2021-02-08
Submitted:0000-00-00
Entered:2021-02-17
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EM9810 / 1 RA / IM

Administered by: Other      Purchased by: ??
Symptoms: Acute myocardial infarction, Blood creatinine increased, Blood lactic acid decreased, Blood urea increased, Cardiac failure congestive, Chest X-ray abnormal, Computerised tomogram normal, Death, Dyspnoea, Fall, Glomerular filtration rate decreased, Hypoxia, Platelet count decreased, General physical health deterioration, Contusion, Brain natriuretic peptide increased, Troponin I increased, Blood alkaline phosphatase increased, Abdominal injury, Chest injury, Bilevel positive airway pressure, Lung opacity, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-08
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? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Allegra daily as needed; Ambien 5mg daily at bedtime; Aspirin 81 daily; Digoxin daily; hydrocodone-acetaminophen 5-325 as needed pain; Pravastatin 20 daily; ramipril 2.5 daily; zoloft 200 daily
Current Illness: Fell 2/4 and struck abdomen and ribs with large amount bruising Brought to ER 2/7 due to increased shortness of breath since COVID vaccine. Patient was admitted with CHF, hypoxia, possible aspiration pneumonia; NSTEMI (refused transfer for cardiology).
Preexisting Conditions: Dementia; CABG; HTN; MI; esophageal varices; Former smoker; liver cirrhosis; absent kidney
Allergies: Sulfa and vicodin vicodin
Diagnostic Lab Data: 2/7-2/8 hospital labs: BUN 29 Cr 1.43 GFR 48 Alk Phos 151 Lactic Acid 2.5 BNP 203 Troponin I 1.28 platelet count 78 COVID-19 Rapid Negative. Chest x-ray with hazy airspace opacities, CT Negative.
CDC 'Split Type':

Write-up: Fall 2/4 hospital admission 2/7/21 with death on 2/8/2021. Patient continued to decline on Bipap he was a DNR/DNI and family decided on comfort measures and he expired 2/8/2021.

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