| VAERS ID: |
932898 (history) |
| Form: |
Version 2.0 |
| Age: |
61.0 |
| Sex: |
Male |
| Location: |
Pennsylvania |
| Vaccinated: | 2020-12-17 |
| Onset: | 2020-12-23 |
| Days after vaccination: | 6 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-10 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EK5730 / 1 |
LA / IM |
Administered by: Private Purchased by: ?
Symptoms: Cardiac arrest,
Cardiac disorder,
Intensive care,
Withdrawal of life support
SMQs:, Torsade de pointes/QT prolongation (broad), Anaphylactic reaction (broad), Arrhythmia related investigations, signs and symptoms (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (narrow), Acute central respiratory depression (broad), Cardiomyopathy (broad), Respiratory failure (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-30
Days after onset: 7
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Amlodipine, Atorvastatin, Xarelto, Aspirin (These were medications listed with our office in 2019. Unknown if this patient was still taking at time of vaccination).
Current Illness:
Preexisting Conditions: High blood pressure. Congenital unicuspid aortic valve s/p aortic valve replacement 2001 & 2011. Pacemaker placement 2011. Melanoma
Allergies: None known.
Diagnostic Lab Data: Unknown.
CDC Split Type:
Write-up: The patient had an apparent cardiac arrest on 12/23/20 and was admitted to the ICU. He was taken off of life support on 12/30/20. He had known cardiac disease. |
