National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

This is VAERS ID 964795

History of Changes from the VAERS Wayback Machine

First Appeared on 1/29/2021

VAERS ID: 964795
VAERS Form:2
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-13
Onset:2021-01-14
Submitted:0000-00-00
Entered:2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Blood culture negative, Diarrhoea, Pyrexia, White blood cell count normal, Mental status changes, Computerised tomogram head normal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Acetaminophen, Aspirin, Axitinib (Inlyta), Bisacodyl, Duloxetine, Ferrous Sulfate, Glucosamine Chondroitin, Norco, Tresiba, Lovastatin, Magnesium, Senna, Tamsulosin, Warfarin
Current Illness: Metastatic Renal Cell Carcinoma Diagnosed with COVID-19 on 12/7/2020, unknown severity of disease. Received first Pfizer SARS-COV-2 vaccine at the end of December
Preexisting Conditions: Insulin dependent Type 2 Diabetes, CKD3, atrial fibrillation, sick sinus syndrome s/p pacemaker on warfarin, hypertension, diastolic heart failure, gastric ulcers, emphysema
Allergies: Penicillin- Swelling of tongue and neck
Diagnostic Lab Data: 1/14/21 CT head unremarkable, blood culture no growth. Normal WBC 1/18/21 blood cultures no growth
CDC 'Split Type':

Write-up: Symptoms of fever (Tmax 102.9), diarrhea, and altered mental status started ~ 24 hours after vaccination. No evidence of septicemia with negative blood cultures Minimal improvement over 3 days, transferred to tertiary care center for MRI brain after which LP was recommended. However family declined as intubation would have been required and was not consistent with patient''s goals of care.


Changed on 5/7/2021

VAERS ID: 964795 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-13
Onset:2021-01-14
Submitted:0000-00-00
Entered:2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Blood culture negative, Diarrhoea, Pyrexia, White blood cell count normal, Mental status changes, Computerised tomogram head normal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Acetaminophen, Aspirin, Axitinib (Inlyta), Bisacodyl, Duloxetine, Ferrous Sulfate, Glucosamine Chondroitin, Norco, Tresiba, Lovastatin, Magnesium, Senna, Tamsulosin, Warfarin
Current Illness: Metastatic Renal Cell Carcinoma Diagnosed with COVID-19 on 12/7/2020, unknown severity of disease. Received first Pfizer SARS-COV-2 vaccine at the end of December
Preexisting Conditions: Insulin dependent Type 2 Diabetes, CKD3, atrial fibrillation, sick sinus syndrome s/p pacemaker on warfarin, hypertension, diastolic heart failure, gastric ulcers, emphysema
Allergies: Penicillin- Swelling of tongue and neck neck
Diagnostic Lab Data: 1/14/21 CT head unremarkable, blood culture no growth. Normal WBC 1/18/21 blood cultures no growth
CDC 'Split Type':

Write-up: Symptoms of fever (Tmax 102.9), diarrhea, and altered mental status started ~ 24 hours after vaccination. No evidence of septicemia with negative blood cultures Minimal improvement over 3 days, transferred to tertiary care center for MRI brain after which LP was recommended. However family declined as intubation would have been required and was not consistent with patient''s goals of care.


Changed on 5/14/2021

VAERS ID: 964795 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Ohio
Vaccinated:2021-01-13
Onset:2021-01-14
Submitted:0000-00-00
Entered:2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1284 / 2 RA / IM

Administered by: Private      Purchased by: ??
Symptoms: Blood culture negative, Diarrhoea, Pyrexia, White blood cell count normal, Mental status changes, Computerised tomogram head normal

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-21
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: Acetaminophen, Aspirin, Axitinib (Inlyta), Bisacodyl, Duloxetine, Ferrous Sulfate, Glucosamine Chondroitin, Norco, Tresiba, Lovastatin, Magnesium, Senna, Tamsulosin, Warfarin
Current Illness: Metastatic Renal Cell Carcinoma Diagnosed with COVID-19 on 12/7/2020, unknown severity of disease. Received first Pfizer SARS-COV-2 vaccine at the end of December
Preexisting Conditions: Insulin dependent Type 2 Diabetes, CKD3, atrial fibrillation, sick sinus syndrome s/p pacemaker on warfarin, hypertension, diastolic heart failure, gastric ulcers, emphysema
Allergies: Penicillin- Swelling of tongue and neck neck
Diagnostic Lab Data: 1/14/21 CT head unremarkable, blood culture no growth. Normal WBC 1/18/21 blood cultures no growth
CDC 'Split Type':

Write-up: Symptoms of fever (Tmax 102.9), diarrhea, and altered mental status started ~ 24 hours after vaccination. No evidence of septicemia with negative blood cultures Minimal improvement over 3 days, transferred to tertiary care center for MRI brain after which LP was recommended. However family declined as intubation would have been required and was not consistent with patient''s goals of care.

New Search

Link To This Search Result:

https://medalerts.org/vaersdb/findfield.php?IDNUMBER=964795&WAYBACKHISTORY=ON


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