National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 1038442

History of Changes from the VAERS Wayback Machine

First Appeared on 2/18/2021

VAERS ID: 1038442
VAERS Form:2
Age:56.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-04
Onset:2021-01-06
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood chloride increased, Blood creatinine increased, Blood glucose increased, Blood potassium increased, Blood sodium increased, Blood urea increased, Death, Glomerular filtration rate decreased, Drug screen positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-06
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: Hospital discharge medications 12/28/20: Tylenol prn; ativan prn; morphine prn; scopolamine prn all other medications were discontinued
Current Illness: Inpatient 12/21/20 with COVID (+ test 12/17/20) and cellulitis of leg treated with antibiotics. Readmitted 12/25-12/28 with seizures and acute kidney injury discharged to SNF on hospice care.
Preexisting Conditions: Obesity, TBI, quadriplegia secondary to GSW; COPD; seizures; gout; neurogenic bowel and bladder; major depressive disorder; dextroscollosis; DM
Allergies: NKA
Diagnostic Lab Data: 12/25 Dilantin level low 9.2 and drug screen positive for barbituates 12/28: glucose 149; BUN 28; Cr 3.39; Bun/Cr ratio 7.9; GFR 19; Na 150; chloride 114 12/27: Potassium 6.2 down within normal range on 12/28 4.2
CDC 'Split Type':

Write-up: Death within thirty days of vaccine. Multiple co-morbidities and placed on hospice 12/28/20.


Changed on 5/7/2021

VAERS ID: 1038442 Before After
VAERS Form:2
Age:56.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-04
Onset:2021-01-06
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood chloride increased, Blood creatinine increased, Blood glucose increased, Blood potassium increased, Blood sodium increased, Blood urea increased, Death, Glomerular filtration rate decreased, Drug screen positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-06
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: Hospital discharge medications 12/28/20: Tylenol prn; ativan prn; morphine prn; scopolamine prn all other medications were discontinued
Current Illness: Inpatient 12/21/20 with COVID (+ test 12/17/20) and cellulitis of leg treated with antibiotics. Readmitted 12/25-12/28 with seizures and acute kidney injury discharged to SNF on hospice care.
Preexisting Conditions: Obesity, TBI, quadriplegia secondary to GSW; COPD; seizures; gout; neurogenic bowel and bladder; major depressive disorder; dextroscollosis; DM
Allergies: NKA NKA
Diagnostic Lab Data: 12/25 Dilantin level low 9.2 and drug screen positive for barbituates 12/28: glucose 149; BUN 28; Cr 3.39; Bun/Cr ratio 7.9; GFR 19; Na 150; chloride 114 12/27: Potassium 6.2 down within normal range on 12/28 4.2
CDC 'Split Type':

Write-up: Death within thirty days of vaccine. Multiple co-morbidities and placed on hospice 12/28/20.


Changed on 5/14/2021

VAERS ID: 1038442 Before After
VAERS Form:2
Age:56.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-04
Onset:2021-01-06
Submitted:0000-00-00
Entered:2021-02-18
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Other      Purchased by: ??
Symptoms: Blood chloride increased, Blood creatinine increased, Blood glucose increased, Blood potassium increased, Blood sodium increased, Blood urea increased, Death, Glomerular filtration rate decreased, Drug screen positive

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-06
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: Hospital discharge medications 12/28/20: Tylenol prn; ativan prn; morphine prn; scopolamine prn all other medications were discontinued
Current Illness: Inpatient 12/21/20 with COVID (+ test 12/17/20) and cellulitis of leg treated with antibiotics. Readmitted 12/25-12/28 with seizures and acute kidney injury discharged to SNF on hospice care.
Preexisting Conditions: Obesity, TBI, quadriplegia secondary to GSW; COPD; seizures; gout; neurogenic bowel and bladder; major depressive disorder; dextroscollosis; DM
Allergies: NKA NKA
Diagnostic Lab Data: 12/25 Dilantin level low 9.2 and drug screen positive for barbituates 12/28: glucose 149; BUN 28; Cr 3.39; Bun/Cr ratio 7.9; GFR 19; Na 150; chloride 114 12/27: Potassium 6.2 down within normal range on 12/28 4.2
CDC 'Split Type':

Write-up: Death within thirty days of vaccine. Multiple co-morbidities and placed on hospice 12/28/20.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1038442&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166