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

This is VAERS ID 892415



Case Details

VAERS ID: 892415 (history)  
Form: Version 2.0  
Age: 82.0  
Sex: Male  
Location: Illinois  
Vaccinated:2020-10-21
Onset:2020-10-21
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2020-10-25
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) / SANOFI PASTEUR UJ546AA / N/A AR / IM

Administered by: Pharmacy       Purchased by: ?
Symptoms: Blood test, Death, Decreased appetite, Intensive care, Lethargy, Malaise, Vomiting
SMQs:, Acute pancreatitis (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2020-10-24
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, 1 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: LEVOTHYROXINE, LISINOPRIL, PREDNISONE, TERAZOSIN, ELIQUIS, ADV
Current Illness: CANCER (PITUITARY GLAND TUMOR, NOT DISCLOSED)
Preexisting Conditions: COPD, HYPERTENSION, BPH, OSTEOPOROSIS, HYPOTHYROIDISM
Allergies: PENICILLINS, OTHERWISE NOT SPECIFIED
Diagnostic Lab Data: BLOODWORK DONE WHEN ADMITTED TO ICU BUT WAS NOT SPECIFIED TO ME
CDC Split Type:

Write-up: Pt felt ill later in the day on 10/21/2020 and vomited. Pt was described as lethargic on 10/22 and 10/23 and lack of appetite also observed those days. Pt was brought to local ER where he was admitted to the ICU. He had bloodwork done when admitted to ICU but was not specified to me. Pt died 10/24 around 3AM


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