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From the 2/26/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 1049428



Case Details

VAERS ID: 1049428 (history)  
Form: Version 2.0  
Age: 70.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-01-28
Onset:2021-02-07
   Days after vaccination:10
Submitted: 0000-00-00
Entered: 2021-02-23
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 RA / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Blood albumin decreased, Blood creatinine normal, Blood glucose increased, Blood sodium increased, Blood urea increased, Body temperature increased, Carbon dioxide increased, Death, Decreased appetite, Discomfort, Dysphagia, Dyspnoea, Feeling cold, Heart rate increased, Hyperhidrosis, Lethargy, Mastication disorder, Peripheral coldness, Prealbumin, Respiratory arrest, Restlessness, SARS-CoV-2 test negative, Unresponsive to stimuli, Vomiting, Weight decreased
SMQs:, Acute renal failure (broad), Anaphylactic reaction (broad), Acute pancreatitis (broad), Hyperglycaemia/new onset diabetes mellitus (narrow), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Arrhythmia related investigations, signs and symptoms (broad), Retroperitoneal fibrosis (broad), Dementia (broad), Akathisia (broad), Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Acute central respiratory depression (narrow), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Cardiomyopathy (broad), Hypotonic-hyporesponsive episode (broad), Chronic kidney disease (broad), Hypersensitivity (broad), Tumour lysis syndrome (broad), Respiratory failure (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad), Infective pneumonia (broad), Dehydration (broad), COVID-19 (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-02-12
   Days after onset: 5
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Aspirin Tablet 81 MG daily; Calcium Citrate-Vitamin D Tablet 315-200 MG daily; Donepezil HCl Tablet Give 10 mg daily; glipiZIDE Tablet 5 MG daily; HydroCHLOROthiazide Tablet 25 MG daily; Latanoprost Emulsion 0.005 % Instill 1 drop in both e
Current Illness: 1/6/2021-Resident noted with increased irritability and increased signs/symptoms of discomfort. Followed by Palliative APRN. Labs ordered and Tylenol increased for pain management. 1/7 labs BUN 28mg/dl/Creatinine 0.53mg/dl. CBC unremarkable. 1/7/2021-1st Pfizer Covid-19 Vaccine dose given. 1/15/2021 Palliative APRN came to visit reviewed labs Valproic Acid level WNL. Hepatic Panel with Albumin low at 2.6g/dl. Plan of care discussed with Guardian. N.O. DNR/DNH, may have draws labs and treat with ABX if needed. 1/24/2021 Patient vomited large amount of undigested food. 1/28/2021 2nd Pfizer Covid-19 Vaccine dose given.
Preexisting Conditions: Hx Covid + June 4, 2020; HYPERLIPIDEMIA, UNSPECIFIED (E78.5); UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE; TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65); ESSENTIAL (PRIMARY) HYPERTENSION (I10); glaucoma; UNSPECIFIED MOOD [AFFECTIVE] DISORDER (F39); HYPOKALEMIA (E87.6); GASTROESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS (K21.9); HYPERLIPIDEMIA, UNSPECIFIED (E78.5);
Allergies: Nylons
Diagnostic Lab Data: Labs 2/10 BMP- Glucose 248mg/dl; BUN 31mg/dl; Creatinine 0.54mg/dl; Sodium 149mmol/L; CO2 36mmol/L; Albumin 3.0g/dl; Pre-Albumin 19.9mg/dl
CDC Split Type:

Write-up: 2/7/21 Increased difficulty chewing, swallowing, evaluated by SLP and dietician. Diet texture down-graded x 2 with poor appetite and recent 6lb weight loss. 2/8/21-APRN updated regarding poor appetite and difficulty chewing as well as downgraded texture of diet. Also informed of increased s/s of discomfort and increased use of PRN Oxycodone for pain. 2/9/21- elevated temp 100.7. 2/9/21 Covid pcr test negative. 2/9/21-N.O.?s APRN BMP, Albumin and Pre-albumin Level in am. 2/11/21-elevated temp 100.4. Covid rapid test negative. 2/12/21- CBG recorded at 517 at 5:20 am. Resident also has an elevated temp of 100.9. Tylenol administered per order. Vital signs include resp 24, radial pulse 134, O2 sat 83%. Supplemental oxygen administered via nasal cannula. Head of bed elevated. DR. notified at time via telephone. Order given for sliding scale for CBG. Guardian updated regarding changes in residents condition, poor prognosis. Guardian requests Hospice eval and admit. Guardian requests comfort care no hospitalization, no IV''s, no G-tubes, no labs etc, D/C of Palliative services. ARNP informed. 2/12/21 Acute Telehealth visit with APRN due to increased lethargy, elevated CBG?s despite poor appetite and insulin administration. Resident unresponsive to verbal and noxious stimuli at time of visit. N.O. Morphine sulfate 20mg/ml, give 2.5mg PO/SL Q4hr PRN pain/shortness of breath. 2/12/2021-Admitted to Hospice, Lethargic, diaphoretic, T 98.1 P 130''s R 18 O2 high 80''s to low 90''s via O2 mask at 3L. 2/12/2021- Resident legs and arms noted to feel cool this afternoon, 02 sat was 97% with 02 on @ 3L with mask Noted resident with sob and increased pulse. Prn morphine 0.25ml sl. given with good effect. Resident was less restless and quiet in her bed. Checked on resident several times this shift for needs. Resident noted to not move in her bed @ 8:15pm and noted she was not breathing. Supervisor called and pronounced resident deceased.


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