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This is VAERS ID 920545

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 920545
VAERS Form:2
Age:93.0
Sex:Male
Location:South Dakota
Vaccinated:2021-01-04
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood pressure abnormal, Fatigue, Pulse absent, Respiratory arrest, Limb discomfort, Abnormal behaviour

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-04
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? No
Previous Vaccinations:
Other Medications: Ferrex 150 mg, Folic Acid 1 mg, Furosemide 20 mg, Isosorbide Mononoitrate ER 30 mg, Lactulose 15 mL, Omeprazole 40 mg, Potassium Chloride ER 20 MEQ, Metoprolol 12.5 mg, PreserVision AREDS 2 one capsule, Ranolazine ER 1,000 mg, and Sucralf
Current Illness:
Preexisting Conditions: ACUTE POSTHEMORRHAGIC ANEMIA, ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITH OTHER FORMS OF ANGINA PECTORIS, CARDIAC MURMUR, UNSPECIFIED, CHRONIC KIDNEY DISEASE, STAGE 2, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, EMPHYSEMA, ESSENTIAL (PRIMARY) HYPERTENSION, FRACTURE OF NASAL BONES, INITIAL ENCOUNTER FOR CLOSED FRACTURE, HYPOXEMIA, PAROXYSMAL ATRIAL FIBRILLATION, PRESENCE OF CARDIAC PACEMAKER, THROMBOCYTOPENIA, UNSPECIFIED CIRRHOSIS OF LIVER, and UNSPECIFIED DIASTOLIC (CONGESTIVE) HEART FAILURE.
Allergies: NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The resident received is vaccine around 11:00 am and tolerated it without any difficulty or immediate adverse effects. He was at therapy from 12:36 pm until 1:22 pm when he stated he was too tired and could not do anymore. The therapist took him back to his room at that time and he got into bed himself but stated his legs felt heavy. At 1:50 pm the CNA answered his call light and found he had taken himself to the bathroom. She stated that when he went to get back into the bed it was "abnormal" how he was getting into it so she assisted him. At that time he quit breathing and she called a RN into the room immediately. He was found without a pulse, respirations, or blood pressure at 1:54 pm. He was a DNR.


Changed on 5/7/2021

VAERS ID: 920545 Before After
VAERS Form:2
Age:93.0
Sex:Male
Location:South Dakota
Vaccinated:2021-01-04
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood pressure abnormal, Fatigue, Pulse absent, Respiratory arrest, Limb discomfort, Abnormal behaviour

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-04
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? No
Previous Vaccinations:
Other Medications: Ferrex 150 mg, Folic Acid 1 mg, Furosemide 20 mg, Isosorbide Mononoitrate ER 30 mg, Lactulose 15 mL, Omeprazole 40 mg, Potassium Chloride ER 20 MEQ, Metoprolol 12.5 mg, PreserVision AREDS 2 one capsule, Ranolazine ER 1,000 mg, and Sucralf
Current Illness:
Preexisting Conditions: ACUTE POSTHEMORRHAGIC ANEMIA, ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITH OTHER FORMS OF ANGINA PECTORIS, CARDIAC MURMUR, UNSPECIFIED, CHRONIC KIDNEY DISEASE, STAGE 2, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, EMPHYSEMA, ESSENTIAL (PRIMARY) HYPERTENSION, FRACTURE OF NASAL BONES, INITIAL ENCOUNTER FOR CLOSED FRACTURE, HYPOXEMIA, PAROXYSMAL ATRIAL FIBRILLATION, PRESENCE OF CARDIAC PACEMAKER, THROMBOCYTOPENIA, UNSPECIFIED CIRRHOSIS OF LIVER, and UNSPECIFIED DIASTOLIC (CONGESTIVE) HEART FAILURE.
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The resident received is vaccine around 11:00 am and tolerated it without any difficulty or immediate adverse effects. He was at therapy from 12:36 pm until 1:22 pm when he stated he was too tired and could not do anymore. The therapist took him back to his room at that time and he got into bed himself but stated his legs felt heavy. At 1:50 pm the CNA answered his call light and found he had taken himself to the bathroom. She stated that when he went to get back into the bed it was "abnormal" how he was getting into it so she assisted him. At that time he quit breathing and she called a RN into the room immediately. He was found without a pulse, respirations, or blood pressure at 1:54 pm. He was a DNR.


Changed on 5/14/2021

VAERS ID: 920545 Before After
VAERS Form:2
Age:93.0
Sex:Male
Location:South Dakota
Vaccinated:2021-01-04
Onset:2021-01-04
Submitted:0000-00-00
Entered:2021-01-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0140 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood pressure abnormal, Fatigue, Pulse absent, Respiratory arrest, Limb discomfort, Abnormal behaviour

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-04
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? No
Previous Vaccinations:
Other Medications: Ferrex 150 mg, Folic Acid 1 mg, Furosemide 20 mg, Isosorbide Mononoitrate ER 30 mg, Lactulose 15 mL, Omeprazole 40 mg, Potassium Chloride ER 20 MEQ, Metoprolol 12.5 mg, PreserVision AREDS 2 one capsule, Ranolazine ER 1,000 mg, and Sucralf
Current Illness:
Preexisting Conditions: ACUTE POSTHEMORRHAGIC ANEMIA, ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITH OTHER FORMS OF ANGINA PECTORIS, CARDIAC MURMUR, UNSPECIFIED, CHRONIC KIDNEY DISEASE, STAGE 2, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, EMPHYSEMA, ESSENTIAL (PRIMARY) HYPERTENSION, FRACTURE OF NASAL BONES, INITIAL ENCOUNTER FOR CLOSED FRACTURE, HYPOXEMIA, PAROXYSMAL ATRIAL FIBRILLATION, PRESENCE OF CARDIAC PACEMAKER, THROMBOCYTOPENIA, UNSPECIFIED CIRRHOSIS OF LIVER, and UNSPECIFIED DIASTOLIC (CONGESTIVE) HEART FAILURE.
Allergies: NKA NKA
Diagnostic Lab Data:
CDC 'Split Type':

Write-up: The resident received is vaccine around 11:00 am and tolerated it without any difficulty or immediate adverse effects. He was at therapy from 12:36 pm until 1:22 pm when he stated he was too tired and could not do anymore. The therapist took him back to his room at that time and he got into bed himself but stated his legs felt heavy. At 1:50 pm the CNA answered his call light and found he had taken himself to the bathroom. She stated that when he went to get back into the bed it was "abnormal" how he was getting into it so she assisted him. At that time he quit breathing and she called a RN into the room immediately. He was found without a pulse, respirations, or blood pressure at 1:54 pm. He was a DNR.

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