| VAERS ID: |
942072 (history) |
| Form: |
Version 2.0 |
| Age: |
87.0 |
| Sex: |
Female |
| Location: |
Vermont |
| Vaccinated: | 2021-01-02 |
| Onset: | 2021-01-05 |
| Days after vaccination: | 3 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-13 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
- / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Aspiration,
Death,
Dementia,
SARS-CoV-2 test negative
SMQs:, Dementia (narrow), Noninfectious encephalopathy/delirium (broad), COVID-19 (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-05
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tramadol, risperidone, fluoxetine, cyanocobalamin, colchicine, torsemide, levothyroxine
Current Illness: aspiration pneumonia- completed treatment prior to vaccination.
Preexisting Conditions: Advanced dementia with severe violent behavioral symptoms. Progressive decline and frailty due to late stage dementia with likely terminal aspiration after completion of treatment for previous aspiration pneumonia. Death attributed to complications of her advanced dementia. No evidence of acute reaction to vaccine (rash, dyspnea, swelling, redness). Chronic kidney disease, hypothyroidism, type 2 diabetes, gout, B12 deficiency
Allergies: No known allergies
Diagnostic Lab Data: COVID-19 PCR neg on 12/31/20 and 1/3/21
CDC Split Type:
Write-up: Death occurred 3 days after vaccine receipt; attributed to complications of her chronic advanced dementia with aspiration at age 87. No evidence of acute vaccine reaction. |
