| VAERS ID: |
914690 (history) |
| Form: |
Version 2.0 |
| Age: |
83.0 |
| Sex: |
Female |
| Location: |
California |
| Vaccinated: | 2020-12-23 |
| Onset: | 2020-12-24 |
| Days after vaccination: | 1 |
| Submitted: |
0000-00-00 |
| Entered: |
2020-12-30 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / 1 |
- / - |
Administered by: Senior Living Purchased by: ?
Symptoms: Anxiety,
Death,
Pyrexia,
Respiratory distress,
SARS-CoV-2 test negative
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Acute central respiratory depression (broad), Hypersensitivity (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-26
Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Contact facility for medical records. We think levothyroxine daily and ativan prn.
Current Illness: none known
Preexisting Conditions: COPD
Allergies: none known
Diagnostic Lab Data: We were told her last COVID test was negative
CDC Split Type:
Write-up: Within 24 hours of receiving the vaccine, fever and respiratory distress, and anxiety developed requiring oxygen, morphine and ativan. My Mom passed away on the evening of 12/26/2020. |
