| VAERS ID: |
1066093 (history) |
| Form: |
Version 2.0 |
| Age: |
63.0 |
| Sex: |
Male |
| Location: |
Texas |
| Vaccinated: | 2020-12-30 |
| Onset: | 2021-02-02 |
| Days after vaccination: | 34 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-03-02 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 2 |
UN / UN |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
- / UN |
Administered by: Other Purchased by: ?
Symptoms: Death,
Lethargy,
SARS-CoV-2 test negative
SMQs:, Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Hypoglycaemia (broad), COVID-19 (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-02-12
Days after onset: 10
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations:
Other Medications: Atorvastatin, Suboxone, aspirin, finasteride, Guaiefenesin, imodium, lisinopril, metoprolol, pantoprazole, Prostat sugar free liquid protein (pollen extracts), solifenacin, tamsulosin, Humulin
Current Illness: Hypertension, diabetes mellitus, hyperlipidemia, chronic systolic heart failure, paroxysmal atrial fibrillation, low back pain with intermittent radiculopathic symptoms, history of ruptured gastrointestinal ulcer in 2018 with resultant internal bleeding and cerebrovascular disease with right-sided neurologic deficit, neurogenic bladder with indwelling catheter, Covid-19 positive (7/2020) with subsequent negative tests 12/2020, 01/2021, and 2/2021
Preexisting Conditions: same as other illnesses
Allergies: Unknown
Diagnostic Lab Data:
CDC Split Type:
Write-up: No known side effects; however, on 1/20 the decedent suffered lethargy. On 2/12/2021, the decedent had a possible seizure and was transported to emergency department where shortly after arrival, he was pronounced dead. |
