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This is VAERS ID 892415

History of Changes from the VAERS Wayback Machine

First Appeared on 12/10/2020

VAERS ID: 892415
VAERS Form:2
Age:82.0
Sex:Male
Location:Illinois
Vaccinated:2020-10-21
Onset:2020-10-21
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: Death, Intensive care, Lethargy, Malaise, Vomiting, Decreased appetite, Blood test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-10-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 1     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


Changed on 12/24/2020

VAERS ID: 892415 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Illinois
Vaccinated:2020-10-21
Onset:2020-10-21
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: Death, Intensive care, Lethargy, Malaise, Vomiting, Decreased appetite, Blood test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-10-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 1     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 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


Changed on 12/30/2020

VAERS ID: 892415 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Illinois
Vaccinated:2020-10-21
Onset:2020-10-21
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: Death, Intensive care, Lethargy, Malaise, Vomiting, Decreased appetite, Blood test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-10-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 1     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 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


Changed on 5/7/2021

VAERS ID: 892415 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Illinois
Vaccinated:2020-10-21
Onset:2020-10-21
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: Death, Intensive care, Lethargy, Malaise, Vomiting, Decreased appetite, Blood test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2020-10-24
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 1     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 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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