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This is VAERS ID 916803

History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 916803
VAERS Form:2
Age:78.0
Sex:Male
Location:Louisiana
Vaccinated:2020-10-06
Onset:2020-10-10
Submitted:0000-00-00
Entered:2021-01-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) / SANOFI PASTEUR - / 4 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Pneumothorax

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2020-10-18
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: 8     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril, Novolog,, Lantus Solostar, Gabapentin, Glusosamine-chondrotin, Lanaoprost, Alphagan, Metoprol Tartrate, Colocrys. . as needed, Chlorthlidone.
Current Illness: none
Preexisting Conditions: large T-cell lymphoma, HTN, Gout, recieving treatment for fluide in lags
Allergies: N?A
Diagnostic Lab Data: Hospitalized 10/11/2020 and died 11/18/2020
CDC 'Split Type':

Write-up: respitory colase


Changed on 5/7/2021

VAERS ID: 916803 Before After
VAERS Form:2
Age:78.0
Sex:Male
Location:Louisiana
Vaccinated:2020-10-06
Onset:2020-10-10
Submitted:0000-00-00
Entered:2021-01-01
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU4: INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE QUADRIVALENT) / SANOFI PASTEUR - / 4 - / IM

Administered by: Private      Purchased by: ??
Symptoms: Death, Pneumothorax

Life Threatening? Yes
Birth Defect? No
Died? Yes
   Date died:2020-10-18
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: 8     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Lisinopril, Novolog,, Lantus Solostar, Gabapentin, Glusosamine-chondrotin, Lanaoprost, Alphagan, Metoprol Tartrate, Colocrys. . as needed, Chlorthlidone.
Current Illness: none
Preexisting Conditions: large T-cell lymphoma, HTN, Gout, recieving treatment for fluide in lags
Allergies: N?A N?A
Diagnostic Lab Data: Hospitalized 10/11/2020 and died 11/18/2020
CDC 'Split Type':

Write-up: respitory colase

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https://medalerts.org/vaersdb/findfield.php?IDNUMBER=916803&WAYBACKHISTORY=ON


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