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This is VAERS ID 1043690

History of Changes from the VAERS Wayback Machine

First Appeared on 2/26/2021

VAERS ID: 1043690
VAERS Form:2
Age:76.0
Sex:Male
Location:Idaho
Vaccinated:2021-02-18
Onset:2021-02-19
Submitted:0000-00-00
Entered:2021-02-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Sudden death, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-19
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: Aspirin 325 mg 1 tab po daily Lisinopril 5 mg 1 tab po daily Metoprolol succinate 50 mg 1 tab po bid Sotalol 120 mg 1.5 tab po bid Alfuzosin 10 mg 1 tab po daily Myrbetriq 50 mg 1 tab po daily Diltiazem 240 mg 1 tab po daily Rosuvastatin 40
Current Illness:
Preexisting Conditions: HLD, GERD, OSA, rosacea, pulmonary HTN, HTN, CAD, hx of prostate cancer, sinus node dysfunction, aortic stenosis, diastolic dysfunction, cardiac pacemaker
Allergies: Amiodarone - pulmonary toxicity Lipitor - rash Penicillins - mild hives Adhesive tape/silicones - rash
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Ventricular fibrillation/sudden death


Changed on 5/7/2021

VAERS ID: 1043690 Before After
VAERS Form:2
Age:76.0
Sex:Male
Location:Idaho
Vaccinated:2021-02-18
Onset:2021-02-19
Submitted:0000-00-00
Entered:2021-02-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Sudden death, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-19
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: Aspirin 325 mg 1 tab po daily Lisinopril 5 mg 1 tab po daily Metoprolol succinate 50 mg 1 tab po bid Sotalol 120 mg 1.5 tab po bid Alfuzosin 10 mg 1 tab po daily Myrbetriq 50 mg 1 tab po daily Diltiazem 240 mg 1 tab po daily Rosuvastatin 40
Current Illness:
Preexisting Conditions: HLD, GERD, OSA, rosacea, pulmonary HTN, HTN, CAD, hx of prostate cancer, sinus node dysfunction, aortic stenosis, diastolic dysfunction, cardiac pacemaker
Allergies: Amiodarone - pulmonary toxicity Lipitor - rash Penicillins - mild hives Adhesive tape/silicones - rash rash
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Ventricular fibrillation/sudden death


Changed on 5/14/2021

VAERS ID: 1043690 Before After
VAERS Form:2
Age:76.0
Sex:Male
Location:Idaho
Vaccinated:2021-02-18
Onset:2021-02-19
Submitted:0000-00-00
Entered:2021-02-20
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6201 / 1 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Sudden death, Ventricular fibrillation

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-02-19
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: Aspirin 325 mg 1 tab po daily Lisinopril 5 mg 1 tab po daily Metoprolol succinate 50 mg 1 tab po bid Sotalol 120 mg 1.5 tab po bid Alfuzosin 10 mg 1 tab po daily Myrbetriq 50 mg 1 tab po daily Diltiazem 240 mg 1 tab po daily Rosuvastatin 40
Current Illness:
Preexisting Conditions: HLD, GERD, OSA, rosacea, pulmonary HTN, HTN, CAD, hx of prostate cancer, sinus node dysfunction, aortic stenosis, diastolic dysfunction, cardiac pacemaker
Allergies: Amiodarone - pulmonary toxicity Lipitor - rash Penicillins - mild hives Adhesive tape/silicones - rash rash
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Ventricular fibrillation/sudden death

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1043690&WAYBACKHISTORY=ON

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