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This is VAERS ID 366976

Case Details

VAERS ID: 366976 (history)  
Form: Version 1.0  
Age: 61.0  
Sex: Male  
Location: New Jersey  
   Days after vaccination:1
Submitted: 2009-11-12
   Days after onset:14
Entered: 2009-11-12
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Other       Purchased by: Public
Symptoms: Death, Dyspnoea, Feeling cold, Oedema, Pain
SMQs:, Cardiac failure (broad), Anaphylactic reaction (narrow), Angioedema (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Haemodynamic oedema, effusions and fluid overload (narrow), Cardiomyopathy (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2009-11-10
   Days after onset: 12
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 13 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications: AMBIEN; amiodarone; Bayer Aspirin; clonidine HCl; COLACE; DULCOLAX; FERRLECIT; FLOMAX; heparin sodium (porcine); hydroxyzine HCl; LEVOXYL; NEPHROCAPS; normal saline; oxygen; PEPCID; PERCOCET; PhosLo; PROAMATINE; TRILEPTAL; TYLENOL; ZEMPLAR;
Current Illness:
Preexisting Conditions: Allergies: Nitrous oxide; Novacaine; PMH: see below *. PMH: Severe peripheral vascular disease. Amputation of left leg. hypertension, hypertensive cardiovascular disease, diabetes mellitus, cerebrovascular accident in the past, End-stage renal disease on hemodialysis, coronary artery disease, chronic obstructive coronary disease, seizure disorder.
Diagnostic Lab Data: obtained at our medical center. LABS and DIAGNOSTICS: Chest X-ray - Abnormal, nodule left lung. CBC - RBC 3.21 Mill/uL (L) HGB 11.2 g/dL (L) HCT 32.2% (L) MCV 102.0 fL (H) MCH 35.0 pg (H) RDW 21.2% (H) Platelets 67 Thou/uL (L). CHEM - Chloride 96 mmol/L (L) CO2 33 mmol/L (H) Creatinine 3.6 mg/dL (H) BUN CREAT Ratio 9.3 (L) Glucose 138 mg/dL (H) eGFR 17 mL/min (L).
CDC Split Type:

Write-up: Pre dialysis on 10/30/09 complained of achiness (generalized), feeling cold, difficulty breathing. Lungs were clear (oxygen administered w/ ease of breathing), BP 129/41, HR 81 - regular temp 98.38. TYLENOL given for pain #7/10 on pain scale. Patient 3.4 kg $g EDW. Edema +2 pitting in right leg. Reported patient condition to Nephrologist. Hemodialysis treatment initiated and completed without complication. Patient refused to be evaluated at ER and discharged home in stable condition. 11/13/09 Medical records received. Dialysis records for DOS 10/28-10/30. C/o fainting x3 at home. Can''t stay awake. Vaccine given same day (10/28). Admits he had called 911 x2 looking for help that day. Seen 2 days later and c/o coldness, hurting all over. Can''t breath. Kept asking for help. Staff offered to call 911. Refused. Afebrile. No flu like sx noted by staff other than achy. Dialysis tx given. D/C to home. Follow-up call made. Pt OK. Went to bed. 11/16/09 Two discharge summaries received, hospital records. Service dates 10/30/09 to 11/10/09. Assessment: Dehydration, swine flu reaction, Patient presented with fevers, generalized aches, and pains. Very weak and sick. Headache. Non-healing ulcer on right heel. While in hospital became lethargic and difficult to arouse. Developed high fever (105.5), more confused and lethargic. Bradycardic, patient intubated, lost peripheral pulses, resusitation not sucessful, pronounced deceased. 0/04/2010 Death Certificate received. DOD 11/10/2009. Cause of Death: Coronary artery disease, severe peripheral vascular disease, chronic obstructive pulmonary disease, septicemia. Other significant conditions: Status post left below knee amputation, depression, diabetes.

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