VAERS ID: |
952704 (history) |
Form: |
Version 2.0 |
Age: |
79.0 |
Sex: |
Male |
Location: |
Oklahoma |
Vaccinated: | 2021-01-14 |
Onset: | 2021-01-14 |
Days after vaccination: | 0 |
Submitted: |
0000-00-00 |
Entered: |
2021-01-18 |
Vaccination / Manufacturer |
Lot / Dose |
Site / Route |
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH |
- / UNK |
- / - |
Administered by: Other Purchased by: ? Symptoms: Abdominal pain upper,
Abnormal behaviour,
Agitation,
Anxiety,
Completed suicide,
Confusional state,
Dementia,
Dyspnoea,
Panic disorder,
Pyrexia,
SARS-CoV-2 test negative,
Tremor,
Vaccination complication SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Suicide/self-injury (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (narrow), Parkinson-like events (broad), Acute central respiratory depression (broad), Psychosis and psychotic disorders (broad), Pulmonary hypertension (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Cardiomyopathy (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), COVID-19 (broad)
Life Threatening? No
Birth Defect? No
Died? Yes
Date died: 2021-01-16
Days after onset: 2
Permanent Disability? No
Recovered? No Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? No
Previous Vaccinations: Other Medications: Daughter does not know all medications to list at time of reporting Current Illness: Pneumonia 12/20 not Covid19 related Preexisting Conditions: COPD, Curvature of Spine pressed against lung, High blood pressure, Diabetes Allergies: N/A Diagnostic Lab Data: Covid 19 : negative and pt lungs clear, all else unknown to reporter -- Daughter CDC Split Type:
Write-up: Daughter call in for VAERS report to file for father whom committed suicide 1/16/2021 in the AM after reportable ae of COVID 19 vaccine administered 1/14/2021. Patient sought care twice at ER; first visit by ambulance around 5PM and Friday 1/15/2021 Medical Center: Emergency Room. 1st Discharge summary diagnosis: adverse reaction to COVID shot; 2nd Discharge summary diagnosis: adverse reaction to COVID shot, fever, Panic Disorder-- ER. Medical Center Discharge summary diagnosis: Adverse reaction to the vaccine, acute anxiety. Reportable patient symptoms at, 1st visit : fever, shaking stomach cramps, breathing issues. Medical Center -- No fever, confusion and dementia type, patient would not stay in patient bed; patient would get up and sit down again repeatedly, agitated and anxious. Attempted to urinated hospital bed. Patient committed suicide in home. |