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From the 5/14/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 1019911



Case Details

VAERS ID: 1019911 (history)  
Form: Version 2.0  
Age: 77.0  
Sex: Male  
Location: Wisconsin  
Vaccinated:2021-01-25
Onset:2021-02-09
   Days after vaccination:15
Submitted: 0000-00-00
Entered: 2021-02-10
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH - / 1 - / IM

Administered by: Unknown       Purchased by: ?
Symptoms: COVID-19, Condition aggravated, Death, Dyspnoea, Exposure to SARS-CoV-2, Fatigue, Mechanical ventilation, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Cardiomyopathy (broad), Respiratory failure (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-09
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? Yes, 12 days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness: Tested positive for COVID-19 on 01/26/2021 (Antigen positive) - presented to ED due to shortness of breath and fatigue
Preexisting Conditions: Active Problems Noted Date Hypokalemia 1/28/21 Pneumonia due to COVID-19 virus 1/28/21 Acute hypoxemic respiratory failure 1/28/21 Stone of salivary gland or duct 1/8/21 Recurrent major depressive disorder, in partial remission 1/7/21 Secondary hyperparathyroidism of renal origin 1/7/21 Abnormal blood smear 7/22/20 Alkaline reflux gastritis 1/2/20 Severe obesity (BMI 35.0-39.9) with comorbidity 12/20/18 Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin 12/20/18 Morbid obesity due to excess calories 6/18/18 Psoriasis 12/13/17 Proteinuria 10/20/17 Bilateral leg edema 12/5/16 Hypertriglyceridemia 6/27/16 Essential hypertension with goal blood pressure less than 130/85 6/27/16 Anxiety, generalized 6/27/16 Hypothyroid 11/24/14 Aortic valve replaced 7/7/14 Pulmonary emphysema 1/22/09 Obstructive sleep apnea syndrome 8/4/1943 Resolved Problems Noted Date Resolved Date Other chest pain 10/29/19 10/30/19 Chest pain 10/29/19 10/30/19 Type 2 diabetes mellitus without complication, without long-term current use of insulin 6/24/19 7/6/20 Sialadenitis 1/4/19 1/2/20 Obesity (BMI 35.0-39.9 without comorbidity) 12/20/18 1/29/21 Abdominal pain 11/21/18 1/2/20 Type 1 diabetes mellitus with stage 3 chronic kidney disease 6/18/18 6/18/18 CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min 10/20/17 1/2/20 Sarcoidosis of lung 6/27/16 6/26/20 Uncontrolled type 2 diabetes mellitus with stage 3 chronic kidney disease, without long-term current use of insulin 6/27/16 12/13/17 Overview: Recent onset HbA1C 4/21/16 11.9. Last FBS-110 5/17/16 Diabetic eye exam 9/23/16 no diabetic retinopathy. fup one year. Hypothyroidism (acquired) 6/27/16 12/13/17 Exertional dyspnea 6/27/16 6/26/20 Tobacco abuse 11/19/08 9/23/11 documented as of this encounter (statuses as of 01/29/2021) Patient Active Problem List Diagnosis ? Obstructive sleep apnea syndrome ? Pulmonary emphysema (*) ? Aortic valve replaced ? Hypothyroid ? Hypertriglyceridemia ? Essential hypertension with goal blood pressure less than 130/85 ? Anxiety, generalized ? Bilateral leg edema ? Proteinuria ? Psoriasis ? Morbid obesity due to excess calories (*) ? Obesity (BMI 35.0-39.9 without comorbidity) ? Severe obesity (BMI 35.0-39.9) with comorbidity (*) ? Type 2 diabetes mellitus with diabetic neuropathy, without long-term current use of insulin (*) ? Alkaline reflux gastritis ? Abnormal blood smear ? Recurrent major depressive disorder, in partial remission (*) ? Secondary hyperparathyroidism of renal origin (*) ? Stone of salivary gland or duct ? Hypokalemia ? COVID-19 virus infection ? Acute hypoxemic respiratory failure (*) Past Medical History: Diagnosis Date ? Anxiety ? Arthritis ? Asthma ? Back pain ? Chronic kidney disease, stage II (mild) 10/20/2017 ? Dependent edema ? DJD (degenerative joint disease) ? Gastritis ? Glucose intolerance (impaired glucose tolerance) ? History of pulmonary function tests 10/20/2010 showing decreased lung flow consistent with normal variant versus mild obstruction and emphysema ? History of stress test 12/2009 Normal ? Hyperlipidemia ? Hypothyroid Previously had hyperthyroidism ? Kidney stone 05/1999 Right ? Proteinuria 10/20/2017 ? Psoriasis ? Sarcoidosis ? Sleep apnea Past Surgical History: Procedure Laterality Date ? AORTIC VALVE REPLACEMENT 05/2001 #25 St. Jude''s aortic valve replacement ? APPENDECTOMY 1960''s ? CHOLECYSTECTOMY 1994 ? COLONOSCOPY 2010 ? COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD N/A 11/21/2018 COLONOSCOPY with hot polypectomy snare ? OTHER SURGICAL HISTORY 09/2018 spot removed from left arm ? TOTAL KNEE ARTHROPLASTY Right 11/19/2012 ? UPPER GI ENDOSCOPY,DIAGNOSIS N/A 11/21/2018 EGD with cold biopsies performed ? WISDOM TOOTH EXTRACTION
Allergies: Review of patient''s allergies indicates: Allergies Allergen Reactions ? Other [Uncoded Nonscreenable Allergen] Rash Neoprene
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client was administered the vaccine while symptomatic (01/25/21) although client did not know he was symptomatic for COVID-19. He had been exposed to a family member who had tested positive and should have been in quarantine but wasn''t either because it was not felt he was considered a close contact by his family opinion or his family member never notified public health of this close contact...?. Clinet had presented to the ED following day after vaccination for shortness of breath and fatigue and an antigen test showed he was positive for COVID-19. He was sent home that same day 01/26/21. He was back in ED on 01/28/21 for worsening symptoms and admitted to hospital and later placed on ventilator. He passed away on 02/09/2021 (date of death was per his wife).


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