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VAERS ID: | 938974 |
VAERS Form: | 2 |
Age: | 88.0 |
Sex: | Male |
Location: | Ohio |
Vaccinated: | 2021-01-06 |
Onset: | 2021-01-11 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-12 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH | EJ1685 / 1 | LA / IM |
Administered by: Senior Living Purchased by: ??
Symptoms: Death, Diarrhoea, Haematemesis, Haematochezia, Haemoglobin decreased, Vomiting, Decreased appetite
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2021-01-11
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:
Current Illness: Hospice
Preexisting Conditions:
Allergies: NKDA
Diagnostic Lab Data: Labs contacted facility with critical lab, Hemoglobin 4.8, at 9:45am after resident passed
CDC 'Split Type':
Write-up: Hospice Resident received first Covid 19 vaccine dose on 1/6/21. 1/7/21 resident had decreased appetite noted in am but ate 100% of meal at dinner. 1/9/21 resident had decreased appetite with emesis x 2, loose BM x 2. Call placed to hospice. 1/10/21 5:44 am resident able to take HS meds, ingest 2 cups of shake. No emesis or loose stool noted. 12PM nurse noted resident not eating meals but ingesting milkshake and medications without any problems. Hospice contacted for change in condition. 1:00 pm hospice ordered Phenergan 12.5 mg Q 6 hrs PRN. Labs to be drawn 1/11/21. Hospice notified POA. 1/11/21 12:24am Resident had blood in stool. Resident denies any pain, on 2L of O2 for comfort.
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