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This is VAERS ID 975434

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First Appeared on 1/29/2021

VAERS ID: 975434
VAERS Form:2
Age:67.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-02
Onset:2021-01-07
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / SYR

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood glucose normal, Cardio-respiratory arrest, Computerised tomogram, Death, Disorientation, Grunting, Oxygen saturation decreased, Pneumonia, Pyrexia, Respiratory failure, Sepsis, Tremor, Vomiting, Abnormal behaviour, Throat clearing

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-09
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: Renvela, Clopidogrel, Coreg, Aceteminophen, amLODIPine Besylate, Atorvastatin Calcium, Benzonatate, Calcium Acetate, Citalopram Hydrobromide, cloNIDine, Cozaar, Diclofenac, Docusate Sodium, Fluticasone-Umeclidin-Vilant Aerosol Powder Breath
Current Illness: OTHER INJURY OF UNSPECIFIED BODY REGION, SUBSEQUENT ENCOUNTER , LOCAL INFECTION OF THE SKIN AND SUBCUTANEOUS TISSUE, UNSPECIFIED , CELLULITIS OF LEFT LOWER LIMB, CELLULITIS OF RIGHT LOWER LIMB , END STAGE RENAL DISEASE , DEPENDENCE ON RENAL DIALYSIS , TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE,UNSTEADINESS ON FEET , CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION, DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED , MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE , COGNITIVE COMMUNICATION DEFICIT, REPEATED FALLS, OTHER LACK OF COORDINATION, SPINAL STENOSIS, LUMBAR REGION WITH NEUROGENIC CLAUDICATION, ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS, OTHER INTERVERTEBRAL DISC DISPLACEMENT, LUMBAR REGION, ESSENTIAL (PRIMARY) HYPERTENSION
Preexisting Conditions: listed in Item 11
Allergies: No Known Allergies
Diagnostic Lab Data: Spoke to RN at ER. Resident had fever of 102.9 upon arrival to the ER. He coded on the way back from his CT scan. He was diagnosed with right sided pnuemonia, respiratory failure and sepsis. Resident just passed away in ER and was not even admitted. Family was there with him
CDC 'Split Type':

Write-up: vomiting x3 1/8/21 1/9/21 00:34 - called to resident room by CNAs, staff stated resident was "different". Vitals taken and 02 sat was low, O2 in room and applied via NC @3L, O2 sat returned to 98 and all other vitals WNL including BS. Resident asked how he felt, stated he felt "okay". Resident exhibiting some shakey movements and clearing throat, states he does not have any phlegm or drainage or trouble swallowing. MD called and updated on situation, voicemail left. 1/9/21 11am- resident has been making a "growling" noise this shift. resident also has tremors. resident alert and answers questions appropriately. when asked if resident wants to go to hospital, resident firmly states "no". vitals wnl. no emesis noted. will continue to monitor resident. 1/9/21 12p- resident not answering questions appropriately. resident only answering yes or no. resident cannot tell me name, or the year, resident cannot state where he is currently or birthdate.


Changed on 5/7/2021

VAERS ID: 975434 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-02
Onset:2021-01-07
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / SYR

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood glucose normal, Cardio-respiratory arrest, Computerised tomogram, Death, Disorientation, Grunting, Oxygen saturation decreased, Pneumonia, Pyrexia, Respiratory failure, Sepsis, Tremor, Vomiting, Abnormal behaviour, Throat clearing

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-09
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: Renvela, Clopidogrel, Coreg, Aceteminophen, amLODIPine Besylate, Atorvastatin Calcium, Benzonatate, Calcium Acetate, Citalopram Hydrobromide, cloNIDine, Cozaar, Diclofenac, Docusate Sodium, Fluticasone-Umeclidin-Vilant Aerosol Powder Breath
Current Illness: OTHER INJURY OF UNSPECIFIED BODY REGION, SUBSEQUENT ENCOUNTER , LOCAL INFECTION OF THE SKIN AND SUBCUTANEOUS TISSUE, UNSPECIFIED , CELLULITIS OF LEFT LOWER LIMB, CELLULITIS OF RIGHT LOWER LIMB , END STAGE RENAL DISEASE , DEPENDENCE ON RENAL DIALYSIS , TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE,UNSTEADINESS ON FEET , CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION, DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED , MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE , COGNITIVE COMMUNICATION DEFICIT, REPEATED FALLS, OTHER LACK OF COORDINATION, SPINAL STENOSIS, LUMBAR REGION WITH NEUROGENIC CLAUDICATION, ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS, OTHER INTERVERTEBRAL DISC DISPLACEMENT, LUMBAR REGION, ESSENTIAL (PRIMARY) HYPERTENSION
Preexisting Conditions: listed in Item 11
Allergies: No Known Allergies Allergies
Diagnostic Lab Data: Spoke to RN at ER. Resident had fever of 102.9 upon arrival to the ER. He coded on the way back from his CT scan. He was diagnosed with right sided pnuemonia, respiratory failure and sepsis. Resident just passed away in ER and was not even admitted. Family was there with him
CDC 'Split Type':

Write-up: vomiting x3 1/8/21 1/9/21 00:34 - called to resident room by CNAs, staff stated resident was "different". Vitals taken and 02 sat was low, O2 in room and applied via NC @3L, O2 sat returned to 98 and all other vitals WNL including BS. Resident asked how he felt, stated he felt "okay". Resident exhibiting some shakey movements and clearing throat, states he does not have any phlegm or drainage or trouble swallowing. MD called and updated on situation, voicemail left. 1/9/21 11am- resident has been making a "growling" noise this shift. resident also has tremors. resident alert and answers questions appropriately. when asked if resident wants to go to hospital, resident firmly states "no". vitals wnl. no emesis noted. will continue to monitor resident. 1/9/21 12p- resident not answering questions appropriately. resident only answering yes or no. resident cannot tell me name, or the year, resident cannot state where he is currently or birthdate.


Changed on 5/14/2021

VAERS ID: 975434 Before After
VAERS Form:2
Age:67.0
Sex:Male
Location:Illinois
Vaccinated:2021-01-02
Onset:2021-01-07
Submitted:0000-00-00
Entered:2021-01-26
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EH9899 / 1 LA / SYR

Administered by: Senior Living      Purchased by: ??
Symptoms: Blood glucose normal, Cardio-respiratory arrest, Computerised tomogram, Death, Disorientation, Grunting, Oxygen saturation decreased, Pneumonia, Pyrexia, Respiratory failure, Sepsis, Tremor, Vomiting, Abnormal behaviour, Throat clearing

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-09
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: Renvela, Clopidogrel, Coreg, Aceteminophen, amLODIPine Besylate, Atorvastatin Calcium, Benzonatate, Calcium Acetate, Citalopram Hydrobromide, cloNIDine, Cozaar, Diclofenac, Docusate Sodium, Fluticasone-Umeclidin-Vilant Aerosol Powder Breath
Current Illness: OTHER INJURY OF UNSPECIFIED BODY REGION, SUBSEQUENT ENCOUNTER , LOCAL INFECTION OF THE SKIN AND SUBCUTANEOUS TISSUE, UNSPECIFIED , CELLULITIS OF LEFT LOWER LIMB, CELLULITIS OF RIGHT LOWER LIMB , END STAGE RENAL DISEASE , DEPENDENCE ON RENAL DIALYSIS , TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE,UNSTEADINESS ON FEET , CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH (ACUTE) EXACERBATION, DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED , MUSCLE WASTING AND ATROPHY, NOT ELSEWHERE CLASSIFIED, UNSPECIFIED SITE , COGNITIVE COMMUNICATION DEFICIT, REPEATED FALLS, OTHER LACK OF COORDINATION, SPINAL STENOSIS, LUMBAR REGION WITH NEUROGENIC CLAUDICATION, ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS, OTHER INTERVERTEBRAL DISC DISPLACEMENT, LUMBAR REGION, ESSENTIAL (PRIMARY) HYPERTENSION
Preexisting Conditions: listed in Item 11
Allergies: No Known Allergies Allergies
Diagnostic Lab Data: Spoke to RN at ER. Resident had fever of 102.9 upon arrival to the ER. He coded on the way back from his CT scan. He was diagnosed with right sided pnuemonia, respiratory failure and sepsis. Resident just passed away in ER and was not even admitted. Family was there with him
CDC 'Split Type':

Write-up: vomiting x3 1/8/21 1/9/21 00:34 - called to resident room by CNAs, staff stated resident was "different". Vitals taken and 02 sat was low, O2 in room and applied via NC @3L, O2 sat returned to 98 and all other vitals WNL including BS. Resident asked how he felt, stated he felt "okay". Resident exhibiting some shakey movements and clearing throat, states he does not have any phlegm or drainage or trouble swallowing. MD called and updated on situation, voicemail left. 1/9/21 11am- resident has been making a "growling" noise this shift. resident also has tremors. resident alert and answers questions appropriately. when asked if resident wants to go to hospital, resident firmly states "no". vitals wnl. no emesis noted. will continue to monitor resident. 1/9/21 12p- resident not answering questions appropriately. resident only answering yes or no. resident cannot tell me name, or the year, resident cannot state where he is currently or birthdate.

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