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This is VAERS ID 1038290

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History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1038290
VAERS Form:2
Age:68.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-03
Onset:2021-02-03
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood creatinine increased, Blood urea increased, Death, Glomerular filtration rate, White blood cell count increased, Lymphocyte percentage decreased

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-03
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine-benazapril; atorvastatin; basaglar Kwikpen; citalopram; clopidrogel; coreg; fenofibrate; glipizide; hydrochlorothiazide; metformin; pantoprazole; ropinirole
Current Illness: Outpatient admission 1/25-1/27 with Hypertension urgency and inability to care for self at home, discharged to Agency; 1/28/21 had a choking episode and continued to decline from there. ER 1/31 and 2/1 for low grade fever and continued decline returned to SNF and wife placed patient on hospice.
Preexisting Conditions: Apnea; diabetes; dyslipidemia; ischemic stroke; prostate disorder; multiple CVAs with residual weakness
Allergies: Sulfa
Diagnostic Lab Data: ER 1/31-2/1 WBC 10.62; Lymph 11.3%; BUN 35; Cr 1.58; GFR 44;
CDC 'Split Type':

Write-up: Death on same day as vaccination


Changed on 5/7/2021

VAERS ID: 1038290 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-03
Onset:2021-02-03
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood creatinine increased, Blood urea increased, Death, Glomerular filtration rate, White blood cell count increased, Lymphocyte percentage decreased

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-03
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine-benazapril; atorvastatin; basaglar Kwikpen; citalopram; clopidrogel; coreg; fenofibrate; glipizide; hydrochlorothiazide; metformin; pantoprazole; ropinirole
Current Illness: Outpatient admission 1/25-1/27 with Hypertension urgency and inability to care for self at home, discharged to Agency; 1/28/21 had a choking episode and continued to decline from there. ER 1/31 and 2/1 for low grade fever and continued decline returned to SNF and wife placed patient on hospice.
Preexisting Conditions: Apnea; diabetes; dyslipidemia; ischemic stroke; prostate disorder; multiple CVAs with residual weakness
Allergies: Sulfa Sulfa
Diagnostic Lab Data: ER 1/31-2/1 WBC 10.62; Lymph 11.3%; BUN 35; Cr 1.58; GFR 44;
CDC 'Split Type':

Write-up: Death on same day as vaccination


Changed on 5/14/2021

VAERS ID: 1038290 Before After
VAERS Form:2
Age:68.0
Sex:Male
Location:Illinois
Vaccinated:2021-02-03
Onset:2021-02-03
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood creatinine increased, Blood urea increased, Death, Glomerular filtration rate, White blood cell count increased, Lymphocyte percentage decreased

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-03
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine-benazapril; atorvastatin; basaglar Kwikpen; citalopram; clopidrogel; coreg; fenofibrate; glipizide; hydrochlorothiazide; metformin; pantoprazole; ropinirole
Current Illness: Outpatient admission 1/25-1/27 with Hypertension urgency and inability to care for self at home, discharged to Agency; 1/28/21 had a choking episode and continued to decline from there. ER 1/31 and 2/1 for low grade fever and continued decline returned to SNF and wife placed patient on hospice.
Preexisting Conditions: Apnea; diabetes; dyslipidemia; ischemic stroke; prostate disorder; multiple CVAs with residual weakness
Allergies: Sulfa Sulfa
Diagnostic Lab Data: ER 1/31-2/1 WBC 10.62; Lymph 11.3%; BUN 35; Cr 1.58; GFR 44;
CDC 'Split Type':

Write-up: Death on same day as vaccination

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