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From the 4/30/2021 release of VAERS data:

This is VAERS ID 851942



Case Details

VAERS ID: 851942 (history)  
Form: Version 2.0  
Age: 88.0  
Sex: Male  
Location: Louisiana  
Vaccinated:2019-10-09
Onset:2019-10-11
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2019-12-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUARIX QUADRIVALENT) / GLAXOSMITHKLINE BIOLOGICALS J9F97 / 1 LA / IM

Administered by: Private       Purchased by: ?
Symptoms: Asthenia, Chest X-ray abnormal, Condition aggravated, Cough, Decreased appetite, Dyspnoea, Increased tendency to bruise, International normalised ratio increased, Lacrimation increased, Memory impairment, Prothrombin time prolonged, Pruritus, Rhinorrhoea
SMQs:, Liver-related coagulation and bleeding disturbances (narrow), Anaphylactic reaction (narrow), Haemorrhage terms (excl laboratory terms) (narrow), Haemorrhage laboratory terms (broad), Dementia (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Cardiomyopathy (broad), Depression (excl suicide and self injury) (broad), Lacrimal disorders (narrow), Hypersensitivity (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2019-10-25
   Days after onset: 14
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: Megestrol Acetate 40mg oral tablet, Coumadin 2mg oral tablet, Amiodarone HCL 200mg oral tablet, Toprol XL 25mg oral tablet, Potassiu, CL ER 20 MEQ tablet, Amitiza 8mcg oral capsule, Norco 10-325mg oral tablet, Doxazosin Mesylate 8mg tab, Am
Current Illness: Pulmonary edema, Left lower lobe pneumonia, Loss of appetite
Preexisting Conditions: Nonsustained paroxysmal ventricular tachycardia, Dysphagia, BMI 20, Nutritional marasmus, Opiod use, CAD, Unspecified disorders arteries and arterioles, Presence of cardiac pacemaker, Sick sinus syndrome, Elevated troponin, Incarcerated ventral hernia, Tinea unguium, Syncope due to orthostatic hypotension, Weakness, Pruritic rash, Ventral hernia w/o obstruction, Partial intestinal obstruction, Pneumonia, Hematemesis, Ileus, Noninfective gastroenteritis and colitis, Pain in thoracic spine, Other specified abnormal findings of blood chemistry, Vomiting, unspecified, Viral intestinal infection, Corns and callosities, Nail dystrophy, Osteophyte, left foot, Pain in left ankle and joints of left foot, Other symptoms and signs involving the musculoskeletal system, Pain in left foot, Ingrowing nail, Chronic sinusitis, unspecified, Other dorsalgia, Essential (primary) hypertension, Paroxysmal atrial fibrillation, Long term (current) use of anticoagulants, Hyperlipidemia, unspecified, Hypothyroidism, unspecified, Abdominal aortic aneurysm, w/o rupture, Nonrheumatic aortic (valve) insufficiency, Benign prostatic hyperplasia w/o lower urinary tract symptoms, Umbilical hernia w/o obstruction or gangrene
Allergies: NKA
Diagnostic Lab Data: 10/09/19 Chest Xray-Atelectasis noted L$gR 10/11/19 PT/INR-abnormal (high)
CDC Split Type:

Write-up: 10/09/2019-Patient presented to PCPs office with chief complaint of watery eyes, runny nose, cough, and SOB. Generalized weakness worsening and appetite continues to decline. Memory continues to decline, Itching in hands. Spontaneous bruising. Treatment-Add Megace for appetite, Hold Coumadin and recheck Friday, Increase Ensure to 3 times daily as tolerated, Eat greens today


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