National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 904107

History of Changes from the VAERS Wayback Machine

First Appeared on 12/24/2020

VAERS ID: 904107
VAERS Form:2
Age:82.0
Sex:Male
Location:Florida
Vaccinated:2020-12-19
Onset:2020-12-19
Submitted:0000-00-00
Entered:2020-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Dyspnoea

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Probiotic Capsule, Macrobid Capsule 100 MG, Simethicone Tablet 80 MG, Meloxicam Tablet 7.5 MG, Asmanex HFA Aerosol 100 MCG/ACT (Mometasone Furoate), Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH (Umeclidinium Bromide), Mirta
Current Illness: SEPSIS, UNSPECIFIED ORGANISM, THROMBOCYTOPENIA, ADULT FAILURE TO THRIVE, CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Preexisting Conditions: COPD, Adult failure to thrive
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident short of breath approximately 10 minutes post vaccination. Staff noted that his baseline upon activity and transferring is generally shortness of breath. Resident wears 2L NC, O2 saturation was 92%, increased to NC to 4 Liters O2 saturation up to 96%. 170/80, heart rate 94, regular rhythm. Sent to hospital.


Changed on 12/30/2020

VAERS ID: 904107 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Florida
Vaccinated:2020-12-19
Onset:2020-12-19
Submitted:0000-00-00
Entered:2020-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Dyspnoea

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Probiotic Capsule, Macrobid Capsule 100 MG, Simethicone Tablet 80 MG, Meloxicam Tablet 7.5 MG, Asmanex HFA Aerosol 100 MCG/ACT (Mometasone Furoate), Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH (Umeclidinium Bromide), Mirta
Current Illness: SEPSIS, UNSPECIFIED ORGANISM, THROMBOCYTOPENIA, ADULT FAILURE TO THRIVE, CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Preexisting Conditions: COPD, Adult failure to thrive
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident short of breath approximately 10 minutes post vaccination. Staff noted that his baseline upon activity and transferring is generally shortness of breath. Resident wears 2L NC, O2 saturation was 92%, increased to NC to 4 Liters O2 saturation up to 96%. 170/80, heart rate 94, regular rhythm. Sent to hospital.


Changed on 5/7/2021

VAERS ID: 904107 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Florida
Vaccinated:2020-12-19
Onset:2020-12-19
Submitted:0000-00-00
Entered:2020-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Dyspnoea

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Probiotic Capsule, Macrobid Capsule 100 MG, Simethicone Tablet 80 MG, Meloxicam Tablet 7.5 MG, Asmanex HFA Aerosol 100 MCG/ACT (Mometasone Furoate), Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH (Umeclidinium Bromide), Mirta
Current Illness: SEPSIS, UNSPECIFIED ORGANISM, THROMBOCYTOPENIA, ADULT FAILURE TO THRIVE, CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Preexisting Conditions: COPD, Adult failure to thrive
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident short of breath approximately 10 minutes post vaccination. Staff noted that his baseline upon activity and transferring is generally shortness of breath. Resident wears 2L NC, O2 saturation was 92%, increased to NC to 4 Liters O2 saturation up to 96%. 170/80, heart rate 94, regular rhythm. Sent to hospital.


Changed on 5/14/2021

VAERS ID: 904107 Before After
VAERS Form:2
Age:82.0
Sex:Male
Location:Florida
Vaccinated:2020-12-19
Onset:2020-12-19
Submitted:0000-00-00
Entered:2020-12-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Dyspnoea

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? Yes, days:     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Probiotic Capsule, Macrobid Capsule 100 MG, Simethicone Tablet 80 MG, Meloxicam Tablet 7.5 MG, Asmanex HFA Aerosol 100 MCG/ACT (Mometasone Furoate), Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH (Umeclidinium Bromide), Mirta
Current Illness: SEPSIS, UNSPECIFIED ORGANISM, THROMBOCYTOPENIA, ADULT FAILURE TO THRIVE, CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Preexisting Conditions: COPD, Adult failure to thrive
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: Resident short of breath approximately 10 minutes post vaccination. Staff noted that his baseline upon activity and transferring is generally shortness of breath. Resident wears 2L NC, O2 saturation was 92%, increased to NC to 4 Liters O2 saturation up to 96%. 170/80, heart rate 94, regular rhythm. Sent to hospital.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=904107&WAYBACKHISTORY=ON


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166