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VAERS ID: | 932898 |
VAERS Form: | 2 |
Age: | 61.0 |
Sex: | Male |
Location: | Pennsylvania |
Vaccinated: | 2020-12-17 |
Onset: | 2020-12-23 |
Submitted: | 0000-00-00 |
Entered: | 2021-01-10 |
Vaccination / Manufacturer (1 vaccine) | Lot / Dose | Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH | EK5730 / 1 | LA / IM |
Administered by: Private Purchased by: ??
Symptoms: Cardiac arrest, Intensive care, Cardiac disorder, Withdrawal of life support
Life Threatening? No
Birth Defect? No
Died? Yes
Date died:2020-12-30
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:
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.
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