| VAERS ID: |
921175 (history) |
| Form: |
Version 2.0 |
| Age: |
77.0 |
| Sex: |
Female |
| Location: |
New Jersey |
| Vaccinated: | 2021-01-03 |
| Onset: | 2021-01-03 |
| Days after vaccination: | 0 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-05 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EJ1686 / 1 |
- / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Body temperature increased,
Dyspnoea
SMQs:, Anaphylactic reaction (broad), Neuroleptic malignant syndrome (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-05
Days after onset: 2
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, ? days
Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: CHF, COPD, DM, heart failure, anemia, sleep apnea
Preexisting Conditions: CHF, COPD, DM, heart failure, anemia, sleep apnea
Allergies: NKA
Diagnostic Lab Data: Epi pen 0.3mg given, sent to ER
CDC Split Type:
Write-up: Resident received Covid Vaccine, noted after 30 mins with labored breathing BP 161/77, HR 116, R 38, T 101.4, |
