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From the 11/19/2021 release of VAERS data:

This is VAERS ID 963057

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Case Details

VAERS ID: 963057 (history)  
Form: Version 2.0  
Age: 96.0  
Sex: Female  
Location: Unknown  
Vaccinated:2021-01-09
Onset:2021-01-09
   Days after vaccination:0
Submitted: 0000-00-00
Entered: 2021-01-21
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL1283 / 1 - / -

Administered by: Unknown       Purchased by: ?
Symptoms: Abdominal pain, Asthenia, Atrial fibrillation, Azotaemia, Bilevel positive airway pressure, Death, Fatigue, General physical health deterioration, Hypertensive urgency, Hypoxia, Intensive care, Sepsis, Urine output decreased
SMQs:, Acute renal failure (narrow), Acute pancreatitis (broad), Asthma/bronchospasm (broad), Supraventricular tachyarrhythmias (narrow), Retroperitoneal fibrosis (broad), Acute central respiratory depression (broad), Pulmonary hypertension (broad), Guillain-Barre syndrome (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypertension (narrow), Eosinophilic pneumonia (broad), Chronic kidney disease (narrow), Respiratory failure (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Infective pneumonia (broad), Dehydration (broad), Sepsis (narrow), Opportunistic infections (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-17
   Days after onset: 8
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Hospitalized? Yes, ? days
   Extended hospital stay? No
Previous Vaccinations:
Other Medications:
Current Illness:
Preexisting Conditions: hypertension, hypothyroidism, emphysema, CKD 3, and history of breast cancer
Allergies:
Diagnostic Lab Data:
CDC Split Type:

Write-up: presented to ED 1/9/21 with abdominal pain, progressive worsening weakness and fatigue and new onset A fib with RVR likely due to hypertensive urgency . Patient progressed clinically with severe hypoxia and transferred to ICU and started on BiPAP; progressive decline with decreased urinary output with uremia likely secondary to sepsis. Concern with patient worsening clinical decline, palliative care had been consulted on end of life care. Patient expired 1/17/21


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