National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 5/7/2021 release of VAERS data (an older release, current is 10/8/2021):

This is VAERS ID 1075657

Case Details

VAERS ID: 1075657 (history)  
Form: Version 2.0  
Age: 94.0  
Sex: Female  
Location: Wisconsin  
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Back pain, Condition aggravated, Death
SMQs:, Retroperitoneal fibrosis (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-04
   Days after onset: 3
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Tylenol 650MG BID, Eliquis 2.5MG BID, Furosemide 20MG BID, Morphine 5MG every 2 hours as needed, Potassium Chloride 10 mEq daily, Spironolactone 12.5MG daily, Zolpidem 5MG daily
Current Illness: Currently on Hospice
Preexisting Conditions: Personal history of COVID-19, Acute combined systolic (congestive) and diastolic (congestive) heart failure, Other specified diseases of liver, Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity, Other pulmonary embolism without acute cor pulmonale, Cardiomyopathy, unspecified, Coronary angioplasty status, Essential (primary) hypertension, Hyperlipidemia, unspecified, Age-related osteoporosis without current pathological fracture, Edema, unspecified, Chronic kidney disease, stage 3 (moderate), Anemia, unspecified Note: Acute chronic, Constipation, unspecified, Unspecified fracture of shaft of right fibula, initial encounter for closed fracture, Unspecified sensorineural hearing loss, Syncope and collapse, Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture, Zoster without complications (History of), Acute respiratory failure with hypoxia, Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, Peripheral vascular disease, unspecified, Cerebrovascular disease, unspecified Nonrheumatic aortic (valve) stenosis Atherosclerotic heart disease of native coronary artery without angina pectoris Nonrheumatic aortic (valve) insufficiency Alzheimer''s disease, unspecified
Allergies: Penicillin
Diagnostic Lab Data: Death on 03/04/2020 but was on Hospice
CDC Split Type:

Write-up: Resident was having back pain but did have previous back pain prior too.

New Search

Link To This Search Result:

Government Disclaimer on use of this data

Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166