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This is VAERS ID 1771941

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History of Changes from the VAERS Wayback Machine

First Appeared on 10/15/2021

VAERS ID: 1771941
VAERS Form:2
Age:57.0
Sex:Male
Location:Missouri
Vaccinated:2021-09-30
Onset:2021-10-01
Submitted:0000-00-00
Entered:2021-10-08
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH 30145BA / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Acute respiratory distress syndrome, Hypoxia, Respiratory failure, Septic shock, Pulseless electrical activity, Acute kidney injury

Life Threatening? No
Birth Defect? No
Died? No
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? Yes, days: 7     Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Atrial Fibrillation
Preexisting Conditions:
Allergies: Penicillin
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Hospitalized for acute respiratory distress with hypoxia. Diagnosed with septic shock and respiratory failure, acute renal failure and PEA arrest.


Record is removed as of 10/22/2021

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