| VAERS ID: |
934507 (history) |
| Form: |
Version 2.0 |
| Age: |
89.0 |
| Sex: |
Female |
| Location: |
Massachusetts |
| Vaccinated: | 2021-01-03 |
| Onset: | 2021-01-05 |
| Days after vaccination: | 2 |
| Submitted: |
0000-00-00 |
| Entered: |
2021-01-11 |
| Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
| COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
EL0142 / 1 |
LA / IM |
Administered by: Senior Living Purchased by: ?
Symptoms: Sudden death
SMQs:, Torsade de pointes/QT prolongation (broad), Arrhythmia related investigations, signs and symptoms (broad), Cardiomyopathy (broad), Noninfectious myocarditis/pericarditis (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-05
Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Coumadin 2mg po Sat-Mon-Tues-Thurs Coumadin 1mg po Fri Sun APAP 650 mg po PRN pain or temp above 101 Amiodarone 200mg po daily Ativan 0.5mg po PRN anxiety Claritin 10mg po daily Gabapentin 100mg po BID PRN phantom pain Miralax 17Gm po with
Current Illness: No other illness prior to vaccination or within the month prior
Preexisting Conditions: Covid 19 Recovered spring 2020 Chronic stage 5 kidney disease with dialysis 3 times weekly Chronic diastolic congestive heart failure Chronic A-fib Diabetes Mellitus with other circulatory complications Hypertension Right and Left Below the knee amputations
Allergies: KNDA KNFA
Diagnostic Lab Data:
CDC Split Type:
Write-up: Resident died suddenly and expectantly on 01/05/2021 | 