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This is VAERS ID 987533

History of Changes from the VAERS Wayback Machine

First Appeared on 2/4/2021

VAERS ID: 987533
VAERS Form:2
Age:91.0
Sex:Male
Location:California
Vaccinated:2021-01-28
Onset:2021-01-29
Submitted:0000-00-00
Entered:2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL3249 / 2 RA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Death, Full blood count, Lethargy, Metabolic function test

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-29
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: Insulin Lispro, Propranolol 120mg, Clopidogrel 75mg, Donepezil 10mg, Memantine 10mg, QUEtiapine Fumarate 100mg, Pantoprazole 40mg, Pramipexole Dihydrochloride 1.5mg, predniSONE 20mg, Aspirin 81mg, Atorvastatin Calcium 40mg, Insulin Glarg
Current Illness: See item 12
Preexisting Conditions: COPD, CHF, DM, Asthma, HTN, Dementia, Depression, GERD, Parkinson
Allergies: Dexamethasone, Versed
Diagnostic Lab Data: Stat CBC & CMP ordered. Labs were drawn but the patient expired before the facility received the results.
CDC 'Split Type':

Write-up: The patient was observed to be lethargic on 1/29/21 at 1515. BP-80/50, P-75, RR-27, T-100.1. He was given a bolus of NS 150 mlx2. and Rocephin 1 gram IM.

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