VAERS ID: |
915920 (history) |
Form: |
Version 2.0 |
Age: |
96.0 |
Sex: |
Female |
Location: |
Ohio |
Vaccinated: | 2020-12-28 |
Onset: | 2020-12-28 |
Days after vaccination: | 0 |
Submitted: |
0000-00-00 |
Entered: |
2020-12-31 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
ELO140 / UNK |
AR / IM |
Administered by: Senior Living Purchased by: ? Symptoms: Death SMQs:
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2020-12-28
Days after onset: 0
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? 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. |