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This is VAERS ID 1120979

History of Changes from the VAERS Wayback Machine

First Appeared on 3/26/2021

VAERS ID: 1120979
VAERS Form:2
Age:81.0
Sex:Male
Location:Virginia
Vaccinated:2021-03-19
Onset:2021-03-20
Submitted:0000-00-00
Entered:2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Foaming at mouth

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-20
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: APIXABAN 5MG 1 BID APILSOL SOLUTION 5unti/0.1ml TB TEST CARVEDILOL 3.125MG 1 QD ERGOCALCIFEROL 1.25MG 1 EVERY WED EZETIMIBE 10MG 1 QD FERROUS SULFATE 325MG 1 QD FOLIC ACID 1MG 1 QD GABAPENTIN 300MG 1 TID LEVOTHYROXINE 25MCG 1 QD OXYCODONE 5
Current Illness: ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA ANEMIA ACQUIRED COAGULATION FACTOR DEFICIENCY THROMBOCYTOPENIA HYPOTHROIDISM SLEEP APNEA POLYNEUROPATHY ESSENTIAL PRIMARY HYPERTENSION HEMIPLEGIA AD HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING LEFT NON DOMINANT SIDE ESOPHAGITIS GERD CIRRHOSIS OF LIVER NONALCOHOLIC STEATOHEPATITIS ASCITES URINARY DEVICE DEPENDENCE ON SUPPLEMENTAL OXYGEN HISTORYOF FALLING
Preexisting Conditions: SEE ABOVE
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NO IMMEDIATE LOCAL REACTION, NO REACTION 30MINUTES LATER. FOUND FOAMING AT THE MOUTH NEXT MORNING. PRONOUNCED DEAD AT HOSPITAL.


Changed on 5/7/2021

VAERS ID: 1120979 Before After
VAERS Form:2
Age:81.0
Sex:Male
Location:Virginia
Vaccinated:2021-03-19
Onset:2021-03-20
Submitted:0000-00-00
Entered:2021-03-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN6200 / 1 RA / IM

Administered by: Pharmacy      Purchased by: ??
Symptoms: Death, Foaming at mouth

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-03-20
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: APIXABAN 5MG 1 BID APILSOL SOLUTION 5unti/0.1ml TB TEST CARVEDILOL 3.125MG 1 QD ERGOCALCIFEROL 1.25MG 1 EVERY WED EZETIMIBE 10MG 1 QD FERROUS SULFATE 325MG 1 QD FOLIC ACID 1MG 1 QD GABAPENTIN 300MG 1 TID LEVOTHYROXINE 25MCG 1 QD OXYCODONE 5
Current Illness: ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPOXIA ANEMIA ACQUIRED COAGULATION FACTOR DEFICIENCY THROMBOCYTOPENIA HYPOTHROIDISM SLEEP APNEA POLYNEUROPATHY ESSENTIAL PRIMARY HYPERTENSION HEMIPLEGIA AD HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING LEFT NON DOMINANT SIDE ESOPHAGITIS GERD CIRRHOSIS OF LIVER NONALCOHOLIC STEATOHEPATITIS ASCITES URINARY DEVICE DEPENDENCE ON SUPPLEMENTAL OXYGEN HISTORYOF FALLING
Preexisting Conditions: SEE ABOVE
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: NO IMMEDIATE LOCAL REACTION, NO REACTION 30MINUTES LATER. FOUND FOAMING AT THE MOUTH NEXT MORNING. PRONOUNCED DEAD AT HOSPITAL.

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=1120979&WAYBACKHISTORY=ON


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