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VAERS ID: | 915920 |
VAERS Form: | 2 |
Age: | 96.0 |
Sex: | Female |
Location: | Ohio |
Vaccinated: | 2020-12-28 |
Onset: | 2020-12-28 |
Submitted: | 0000-00-00 |
Entered: | 2020-12-31 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH | ELO140 / UNK | AR / IM |
Administered by: Senior Living Purchased by: ??
Symptoms: Death
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2020-12-28
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: Tetanus toxoid
Other Medications: ASA 81, Vitamin D, Vitamin B12, Atorvastatin, Omeprazole, Tylenol, Donepezil, Amlodipine, Coreg, Remeron
Current Illness: Resident was living in an assisted living facility. She fell on 11/24/2020 and was seen in the ER. There, she tested positive for COVID 19. She was admitted to this facility for rehab. She showed a decline after admission and was referred to hospice.
Preexisting Conditions: Vitamin deficiency, hyperlipidemia, hypertension, anemia, dementia, chronic kidney disease III, osteoporosis, history of breast cancer/MI/pulmonary embolism, depression.
Allergies: Tetanus toxoid
Diagnostic Lab Data:
CDC 'Split Type':
Write-up: Resident received vaccine in am and expired that afternoon.
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