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From the 4/30/2021 release of VAERS data:

This is VAERS ID 983173



Case Details

VAERS ID: 983173 (history)  
Form: Version 2.0  
Age: 86.0  
Sex: Female  
Location: Kentucky  
Vaccinated:2021-01-05
Onset:2021-01-21
   Days after vaccination:16
Submitted: 0000-00-00
Entered: 2021-01-28
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EJ1685 / 1 AR / IM

Administered by: Senior Living       Purchased by: ?
Symptoms: Diarrhoea, Hypophagia, Pain, SARS-CoV-2 test positive, Speech disorder, Unresponsive to stimuli, Vital functions abnormal
SMQs:, Hyperglycaemia/new onset diabetes mellitus (broad), Neuroleptic malignant syndrome (broad), Dementia (broad), Pseudomembranous colitis (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypotonic-hyporesponsive episode (broad), Noninfectious diarrhoea (narrow), Hypoglycaemia (broad), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-24
   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: Losartan-HCTZ, Memantine, Metformin, Macrobid, Prilosec, Risperidone, Zocor, Detrol, Benedryl, Aspirin, Centrum, Donepezil, Farxiga, Gabapentin, Vitamin B-12, Vitamin D3, Tylenol
Current Illness: COVID-19
Preexisting Conditions: Alzheimer''s Disease, Anemia, DM type 2, Hyperlipidemia, HTN, GERD
Allergies: Avandia
Diagnostic Lab Data:
CDC Split Type:

Write-up: Client recevied the COVID-19 vaccine on 1/5/21 by the Vaccine clinic. Client tested positive for COVID-19 by rapid testing on 1/21/21, with c/o hurting all over and loose stools. She became non-verbal on 1/23/21 with poor intake. On 1/24/21 at 0537 Client was unresponsive and without vital signs. Orders were for DNR, and CPR was not initiated.


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https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=983173


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