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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 1075710



Case Details

VAERS ID: 1075710 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: New Hampshire  
Vaccinated:2021-01-29
Onset:2021-02-06
   Days after vaccination:8
Submitted: 0000-00-00
Entered: 2021-03-05
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EN5318 / 2 LA / -

Administered by: Senior Living       Purchased by: ?
Symptoms: Agitation, Computerised tomogram head normal, Death, Fall, Insomnia, Magnetic resonance imaging spinal abnormal, Psychotic disorder, Restlessness, Spinal compression fracture, Urinary system X-ray, Urine analysis normal
SMQs:, Systemic lupus erythematosus (broad), Anticholinergic syndrome (broad), Dementia (broad), Akathisia (broad), Psychosis and psychotic disorders (narrow), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Accidents and injuries (narrow), Hostility/aggression (broad), Osteoporosis/osteopenia (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-03-02
   Days after onset: 24
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Medications received day of dose 2 vaccination: Lipitor 80mg, imdur ER 30mg, miralax 17grams, remeron 15mg, 2 tablets preservision areds, 2 tablets senna-s 8.6-50mg, Zoloft 25mg, trazodone 50mg, eliquis 2.5mg BID, coreg 12.5mg BID, Lasix 20
Current Illness: 11. 12/22/21 Desatted on room air that resolved that day and was back on room air. Chest xray showed cardiomegaly. CBC and BMP no acute findings. No medication changes at that time and patient stabilized. 1/6/21 increased edema to legs and new order increase lasix 20mg PO BID X 3 days 1/11/21 Fell and sent to ER for eval of hip pain. Returned same day no acute findings. 1/15/21 Diagnosed with COVID, had congested cough, chest xray showed cardiomegaly. Had CBC, BMP, d-dimer. 1/20/21 started on mucinex 500mg PO BID for continued congested cough 1/21/21 repeat chest xray, CBC and BMP with no acute findings 1/22/21 CBC and BMP no acute findings 1/25/21 COVID quarantine time completed and considered recovered
Preexisting Conditions: 12. Hypertension, osteoarthritis, depression, vascular dementia without behavioral disturbance, repeated falls, old myocardial infarction, GERD, acute on chronic diastolic heart failure, atrial fibrillation, exudative age-related macular degeneration bilateral, nonrheumatic aortic valve stenosis with insufficiency, insomnia, allergic rhinitis, hyperlipidemia,
Allergies: Cipro, Pravachol, sudafed, tricor, depodur, ASA(high dose), micardis, adalat, clonidine, tramadol
Diagnostic Lab Data: See 18
CDC Split Type:

Write-up: 2/6/21 Sent to ER for evaluation of agitation and returned a few hours later on 2/7/21 with no acute findings. 2/7/21 continued with agitation and restlessness and had psychoactive medication changes 2/8/21 Had head CT with no acute findings 2/11/21 MRI of lumbar spine with compression fx T10 2/17/21 UA and KUB done with no acute findings Multiple falls within this time frame with escalating agitation, restlessness, and insomnia. Dx psychosis and started on Seroquel 2/25/21 3/2/21 Patient died


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https://www.medalerts.org/vaersdb/findfield.php?SNAPSHOT=20210514&IDNUMBER=1075710

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