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

This is VAERS ID 986773

Case Details

VAERS ID: 986773 (history)  
Form: Version 2.0  
Age: 67.0  
Sex: Male  
Location: Virginia  
   Days after vaccination:14
Submitted: 0000-00-00
Entered: 2021-01-29
Vaccin­ation / Manu­facturer Lot / Dose Site / Route

Administered by: Senior Living       Purchased by: ?
Symptoms: Acute respiratory failure, Bilevel positive airway pressure, COVID-19, Death, Exposure to SARS-CoV-2, Hospice care, SARS-CoV-2 test positive
SMQs:, Anaphylactic reaction (broad), Shock-associated circulatory or cardiac conditions (excl torsade de pointes) (broad), Torsade de pointes, shock-associated conditions (broad), Hypovolaemic shock conditions (broad), Toxic-septic shock conditions (broad), Anaphylactic/anaphylactoid shock conditions (broad), Hypoglycaemic and neurogenic shock conditions (broad), Acute central respiratory depression (narrow), Hypersensitivity (broad), Respiratory failure (narrow), Infective pneumonia (broad), Opportunistic infections (broad), COVID-19 (narrow)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-18
   Days after onset: 4
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Acetylcysteine Solution 10 % 3 ml inhale orally two times a day BUDESONIDE 30''S,U-D,SDV UD 0.25MG/2ML AMPUL-NEB 2 ml inhale orally two times a day DIVALPROEX SOD ER 500MG TAB.SR 24H Give 1 tablet by mouth at bedtime IPRATROPIUM-ALBUTEROL O
Current Illness: Intermittent episodes of acute on chronic worsening of multi-factorial chronic respiratory failure with clear goals established through advance care planning. Overall, was stable in the month prior to vaccination.
Preexisting Conditions: 1. Status post TBI as a young child resulting in a cerebral palsy like syndrome w/ ID and spastic quadriparesis, R$gL 2. Seizure disorder 3. OBS/Psychiatric disorder with bipolar aspects and psychosis, better on Lithium. Symptoms well-controlled on Paxil, Risperdal and Lithium. 4. Asthmatic bronchitis w/ poor baseline respiratory function (chronic respiratory failure) and chronic cough, stable on regimen of inhaled budesonide, Duonebs and VEST therapy. 5. Complex Sleep apnea, controlled with Bi-PAP 6. GERD, stable on daily PPI. 7. Hypertension, controlled with spironolactone and terazosin. 8. CHF?, stable on spironolactone. Unable to get more records. 9. Hypothyroidism, stable on levothyroxine. 10. Dysphagia with Recurrent Aspiration (Does not want a Peg tube). Stable on puree diet and thickend liquids.
Allergies: Quinolones, Latex, Natural rubber
Diagnostic Lab Data: Nasal swab sample obtained 1/14/21 and sent for PCR testing was positive for SARS-CoV-2.
CDC Split Type:

Write-up: Resident was vaccinated on 12/31/20. Then on 1/14/21 he tested positive for SARS-CoV-2 on routine surveillance PCR testing. Another resident on the same hall was COVID positive on 1/11/21. Results of the PCR test were obtained on 1/16/21. He appeared asymptomatic at that time. Given his COVID positive status, all aerosol generating procedures had to be stopped. Overnight on 1/16/21 into 1/17/21, he had the onset of acute respiratory failure and was transported to the hospital. Per notes, he was put on BiPAP for several hours, but his CO2 level did not improve. Per prior advance directives completed with the resident and his two brothers, he had DNR/DNI orders. The hospital physician spoke with his brother and the decision was made to move to comfort care. He was discharged to inpatient hospice and died around 4pm on 1/18/21. This outcome does not appear to be vaccine-related, but death from COVID-19 infection is listed as a reportable event following COVID-19 vaccination.

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